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SAN JOAQUIN LOCAL HEALTH DISTRICT!. <br /> ,•r_ OFFrCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t , Telephone :- (209) 466-6781 2/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17-f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued / j <br /> (Complete In Triplicate) <br /> Application is hereby made to. the San Joaquin Local Health District fora 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 and� the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION tj CENSUS-TRACT <br /> o <br /> Owner's Name Phone <br /> Address City �ht <br /> Phone <br /> Contractor's Name License if_, ! <br /> TYPE OF WORK (Check) : —N—E-W"WEhL—/ / DEEPEN -/ / RECONDITION-G/ DESTRUCTION /. <br /> PUMP. INSTALLATION PUMP"REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��AA SEWER LINES PIT PRIVYGlt _� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT jj96 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 ' <br /> Domestic/private ;1 Drilled Dia. of Well Casing <br /> I <br /> Domestic/public .1 Driven Gauge of Casing <br /> Irrigation 0 Gravel Pack Depth of Grout Seal. <br /> Cathodic"Protection '11 Rotary Type of Grouti <br /> Disposal Other . Other Information ; <br /> GeophysicalSurface Seal Installed Bill,iii ' <br /> PUMP INSTALLATION: Contractora3ct4 <br /> } Type of Pump H.P. <br /> PUMP REPLACEMENT: 17 State Work done <br /> I PUMP .REPAIR; / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter j 5 '� Approximate Depth <br /> Describe Material and Procedure _ `- <br /> I hereby agree to comply with all laws and regulations of ,ghe San,,Joaquin Local Health District <br /> and the State of California pertaining, to or regulating well-pcorstfuction. Within FIFTEEN DAYS <br /> after completion of my work on 1.a new well, I will furnish the Sail, quip Local Health District <br /> WELL DRILLERS REPORT, of. rhefwell and notify them befZre putting. the well�'in use.... The above <br /> information-is_true-to-the�besl- of=my knowledge-aifd-bel-l-ef:° -I-WILL CAT17FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND 4 FINAL INS?ECTION. TITLEg 4 <br /> SIGNED ����-- <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/1INAL INSPECTION r� <br /> INSPECTION BY DATE INSPECTION BY , DATE ---�/ <br /> b/77 - 2M g <br /> 4 R <br /> F H 1426 Rev. . z--74 - -- <br />