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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> - FOP,jOFFICE USE: � <br /> 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> iM Telephone: (209) 466-6781 i <br /> �p APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ii <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �s- <br /> " (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instail. kthe work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. •1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT * ` <br /> Owner's Name ~ i' <br /> Phone <br /> Address City . <br /> Contractor's Name e -� <br /> Licensehone <br /> TYPE OF WORK ICieck): NEW WELL L;' DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION j&'III­PUMP REPAIR /-7PUMP REPLACEMENT /7 7 <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ,�.. .-� <br /> `SEWAGE DISPOSAL. FIELD _ CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE-��PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.SPECIFICATIONS <br /> =Industrial, Cable Tool Dia. of Well Excavation P� <br /> omestic/pkrivate Drilled Dia. of Well Casing s <br /> Domestic/public Driven ' <br /> t � Gauge g <br /> � �»,...,,. g of Casing i 1. <br /> •—k:--Irrigation <br /> Gravel Pact' Depth of Grout Seal <br /> Cathodic Protection - f <br /> � Rotary Type -of Grout € G irr I <br /> Disposal I Other +"''`_ Other Information <br /> Geophysical — * <br /> Surface Seal Instal26d B <br /> iLL� I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump doT. H.P. <br /> PUMP REPLACEMENT: / / State Work Done 4 -- . <br /> PUMP:REPAIR: 7 State Work Done' <br /> ESIRUCTION OF WELL: Well Diameter l� <br /> N Describe Material and Procedure Approximate Depth 7e <br /> ��/�h <br /> Y hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of: California pertaining to or regulating well construetiah. Within FIFTEEN DAYS <br /> after comgletionjiof my work on a new well, I will furnish the San JoaquiA Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in-use.. The above I <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 FINAL INSPECTION,. <br /> SIGNED <br /> TITLE F <br /> (DRAW PLOT PLAN ON REVERSE SIDE)�� <br />_PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> WFLICATION ACCEPTED BYR <br /> ADDITIONAL COMMENTS: <br /> ��� --� DATE X71 r <br /> P II GAOUT INSOECN PHA II F N INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY TE <br /> E H 1426 m Rev. 1-74 .. i <br /> i - -- .. 1-74 2M <br />