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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ypp1;OFFIGE USE: 1601 E. Hazelton Ave. ,Stockton, Calif. . <br /> Telephone: (209) 4666781 <br /> APPLICATION FUR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete in Triplicate) - o costruct <br /> Application is hereby tiiade to the San Joaquin LoAall cati n ist <br /> tmade in co pliancetwithnSan Joaquin, <br /> and/or install the work herein described. This pp <br /> Count Ordinaned'No. 1862 and the Rules' and Regulations of the San Joaquin Local Health District. <br /> County f <br /> q L L A CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> phone re <br /> Owners Name ILI O <br /> City. - <br /> Address <br /> ity. -Addressi <br /> `License #_2Xg` j Phone $4 7. 6 <br /> Contractor's Nam <br /> DEEPEN -/-7 RECONDITION DESTRUCTION TT <br /> G TYPE OP`WORK (Check): NEW WELL <br /> PUMP INSTALLATION /PUMP REPAIR, PUP REPLACEMENT <br /> t Other / / w <br /> , SEWER LINES PIT PRIVY <br /> ( DISTANCE TO NEAREST: SEPTIC TANK �d CESSPOOL/SEEPAGE PIT � OTHER <br /> f SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DEIMESTIG WELLCONSTRUCTION SPECIFICATIONS <br /> INTENDED'�U. TYPE' OF-WELL <br /> Industrial.._ . Cable Tool Dia. of Well Excavation -a <br /> Domestic/private f~ Drilled. Dia. of Well Casing <br /> Domestic/publics Driven Gauge of Casing t 2 <br /> Irrigation _,,. .'Gravel Pack- Depth of Grout Seal SO ' <br /> Type of Grout <br /> Cathodic Protection �_ Rotary Other Information <br /> Disposal Other , <br /> k Geophysical _ Surface Seal Installed B <br /> y. <br /> PUMP INSTALLATION: Contractor F H.P. <br /> Type .of Pump <br /> PUMP REPLACEMENT: . / / State Work Done,, <br /> PUMP-:REPAIR• .'State..Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I 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 we11'construction. Within FIFTEEN DAYS <br /> rafter completion. of my work on a new well,,. I will furnish the San' Joaquia Local Health District <br /> WELL DRILLERS :REPQRT 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 /> yPRIOR TO GROUTING -AND A FINAL INSPECTION. TITLE -�- <br /> SIGNED ( W p LAN N REVERSE SI <br /> .; f. ..y . z FO DE ARTMENT USE ONLY �.. <br /> PHASF I _ _y} DATE ' <br /> ' APP.LICATION;AGCEP,TLD BY r <br /> , ADDITIONAI.`COMENTS PHASE III FINAL INSPECTIO <br /> PHASE II GROUT INSPEGTI t : DATE <br /> INSPECTION BY DATE // INSPECTION BY <br /> 3 <br /> V U ILIA Dns. 1-71. <br />