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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> -FOK-`OFFICE USE: ` <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS"PERMIT EXPIRES 1 YEAR FROM DATE:ISSUED Date Issued a-�_7� <br /> (Complete In <br /> Application is hereby made to the SonJoaquinTriplicate) <br /> Local Health District for aermi <br /> p t to construct <br /> and/or install the 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/LOC ION AILCENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address Ail <br /> s City " <br /> Contractor's Name - <br /> . License V , Phone � <br /> TYPE OF WORK Check); ° <br /> � NEW WELL / / DEEPEN,'/� RECONDITION /�' DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE-TO NEAREST: -SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY!LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDty USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS E �1 <br /> Industrial Cable Tool' Dia. of Well Excavation � <br /> Domestic/private. .'. . Drilled �`"'"�Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection k Rotary Type of Grout <br /> Disposal Other Other Information . <br /> Geophysical M Surface Seal Installed S <br /> PUMP INSTALLATION: Contractor <br /> kxType of Pump <br /> H.P. <br /> PUMP REPLACEMENT: j!j_ State Work Doiie <br /> PUMP 1,P PAIR: / J State Work Done ` <br />>E$TRUCTION OF WELL: Well Diameter Approximate Depth <br /> s Describe Material and Procedure �`-'--- <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lnd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> kfter completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> TELL 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 GRATjTTWr. AND A FIM, INSPECT 4 . <br /> IGNED <br /> TITLE, I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) --- I <br /> FOR DEPARTMENT USE ONLY <br /> RASE I - <br /> FPr L A ION':ACCEPTED:I BY. r�- <br /> DDITIONAL 6)MMENTS: Z•27-76 �� � DATE -2- -?--2e <br /> �� . <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> N5PECTION:BY' DATE - INSPECTION BY DATE J <br /> '1 <br /> 1426 -Rev. 1-74 1.i7r n.. i <br />