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FOE t3FFTCE'USE• �' SAN OAQUIN LOCKL I1EALT'I; DISTRICT - <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y ' <br /> Telephone:. P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5-- 87t� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -Date Issued <br /> (Complete In Triplicate) /-s- <br /> Application 16 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 <br /> CENSUS TRACT <br /> ' <br /> Owner's Name 41-1 <br /> Phone -. J <br /> Address <br /> City -1 .5 � <br /> Contractor's Name •� ' <br /> License # Phone <br /> TYPE OF WORK (Check); NEW WELL DEEPEN -/? RECONDITION _ <br /> /7 DESTRUCTION /7 <br /> PUMP INSTALLATION <br /> / / PUMP REPAIR / / PUMP REPLACEMENT %f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ., SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> industrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool, Dia. of Well Excavation <br /> Domestic/private, Drilled Dia. of Well Casing 4 <br /> Domestic/public a Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 y Rotary. Type of Grout <br /> Disposal <br /> bther <br /> Geophysical Other Information <br /> . . � �----w.--- <br /> - Surface Seal Installed By: <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT; j/7 State Work Done <br /> PUMP ',REPAIR: / / State Work Done m. <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comp�.y with all laws and regulations of the San 3oagttin Local Health District <br /> and the State of California Pertaining to or regulat,in'g well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DR RS REPOR of the well and notify them before putting the..-well in use.. The above <br /> inform ion{i u h of m knowledge and belief. <br /> PRIOR. G A NSPECTION. g I WILL CALL FQR A GROUT INSPECTION <br /> SIGNED - <br /> TITLE r� <br /> (DRAW PLATPLAN ON REVERSE SIDE) —• <br /> PHASE I FOR DEPARTMENT USE Y <br /> APPLICATION ACCEPTED"BY <br /> ADDITIONAL COMMENTS;.- _ DATE r'�. <br /> 4A / cc �, <br /> PHASE II GROUT INSPECTION / `' ` <br /> INSPECTION BY DATE /S il,/v14 ? PHASE I FINAL NSPECT <br /> INSPECTION- BY DATE <br /> H 1426 <br /> Rev. <br /> E <br />