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' SAN JOAQUIN LOCA HEAITH ISTR CT <br /> FQI~ OFFICE 'USE`S 1601 E. Hazelton Ave. , Stockton, Calif. ­- <br /> Telephone : <br /> alif.Telephone : (209) 466-6781 _--� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued <br /> Application (Complete In Triplicate) . <br /> pp kation 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 compliance with San Joaquin <br /> County Ordinance No.. 1862 and1the Rules and Regulations of the San. Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 7 <br /> S TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # p Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Lt,,ea— 'j <br /> PROPERTYILINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 'V!` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation <br /> Domestic ; <br /> /private ;l Drilled Dia, of Well Casing Q.0 CS <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation TT <br /> I Gravel Pack Depth of Grout Seal ���! ��� <br /> Cathodic ProtectionRotar <br /> Disposal ��' y Type of Grout <br /> Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor h <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: State Work Done <br /> S <br />'UMP -.REPAIR: / / State Work Done <br />►ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> tnd the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS k <br /> ifter completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the well and notify them before Putting- the well in use.... The above <br /> nformation is true to• the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> RIOR TO GR UTING AN AL INSPECTION. ! <br /> IGNED ` <br /> TITLE <br /> RA P OT PL REVERSE SIDE) <br /> HASE I <br /> FOR DEPARTMENT USE ONLY <br /> PPLICA.TION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE S <br /> 4 <br /> PHA$ GRO T INSPECTION PHAS I <br /> NSPECTION BY DATE /FIN INSPECTION <br /> INSPECTION B DATE ; 7 <br /> I <br /> r �• <br /> E H 1426 ` ev. ,1-74 n 2M <br />