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SAN JOAQUIN LOCAL HEALTH. DISTRICT r <br /> FOEa:UFFICE USE: 1601 E. Hazelton Ave.-, Stockton, Calif. �� F <br /> Telephone :' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 .and the Rules`and Regulations o the San Joaquin Local Health District. <br /> —,,,oy�v <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's NameV' License Phone -� <br /> i <br /> TYPE OF WORK (Check) : -NEW-WE•L-L�/-Q DEEPEN_:/, /RECONDITION-%-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR:- "PUMP REPLACEMENT /7 <br /> Other <br /> �az�-�LJ�o � •„ <br /> DISTANCE TO NEAREST: SEPTIC TAN Sp SEWER LINES IT PRIVY Alk <br /> SEWAGE DISPOSAL,MELD VAL CESSPOOL/SEEPAGE PIT /� 0^ OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL&A PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . � <br /> Domestic/private Drilled Dia, of Well Casing ' k <br /> Domestic/public Driven Gauge of Casing ./ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical - Surf a a Seal Installed B : <br /> PUMP INSTALLATION: Contractor ;,_ . <br /> Type.. of Pump-. L H.P. <br /> PUMP REPLACEMENT: . . i�.%/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth Z r <br /> Describe Material, an�fd:Procedure <br /> 41 4 R -, a- f 1 <br /> I hereby agree to comply-with-all:.laws-and�-l:regulations.mof-the-Sa-n-Joaquin Local Health District <br /> and the State of California pertaining_to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will-furnish tIT6 San Joaquin Local Health District a ., <br /> WELL DRILLERS REPORT of the well and -notify them before putting--the-well in use. The above <br /> information is true to ,the best of my knowledge and belief. I WILL CALL FOR `A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F NAL SPECTION. <br /> SIGNED TITLE <br /> DRAW. P T PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY r DATE �? <br /> ADDITIONAL COMMENTS: <br /> .PHASE II GROUT INSPECTION P IY23Ea ANSPECTION <br /> IN ATE INSPECTION BY ATE <br /> E H 1426 <br /> /76 2N <br />