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h <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 7��3� <br /> ii <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 0 Date issued <br /> II THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � k <br /> (Complete In Triplicate) <br /> ApP lication is hereby made to the San Joaquin Local Health District for a permit to <br /> San Joaquin <br /> I <br /> and/or install the work�lherein described. This application is made in comp ianca <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F II � . CENSUS TRACT <br /> JOB ADDRESS/LOCATION Lp0 S <br /> Phone <br /> Owner's Name 4 <br /> city <br /> Address <br /> ar� Phone <br /> ,I License �� <br /> Contractor's Name <br /> ;r <br /> I TYPE OF WORK (Check) : NEW WELL '/ / DEEPE / / RECONDITION Cl DESTRUCTION /7 <br /> t 1PUNP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> 110ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD- CESSPOOL/SEEPAGE PIT OTHER --_ -- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE STIC WELL <br /> �i TYPE OF WELL <br /> Industrial �' Cable Tool Dia. of .Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/privat ' Driven Gauge' of Casing { <br /> Domestic/public :, <br /> Irrigation �) Gravel Pack Depth* of Grout Seal <br /> Cathodic Protection Rota Type. o£ Grout <br /> Other Information <br /> Disposal iI Other <br /> r Geophysical ! Surface Seal Installed B <br /> � r <br /> PUMP INSTALLATION: Contractor4 1 -0 <br /> t Type of Pump H.P. - <br /> t <br /> PUMP REPLACEMENT: �� / / State Work Done <br /> E <br /> li / / State Woron <br /> PUMP .REPAIR: k De <br /> !• DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> q Describe Material and Procedure <br /> i 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 well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT 'of the well and notify them before putting the well in use. The above. <br /> IJ <br /> information is true to the best of my knowledge and belief. I WILL C FOR A GROUT INSPECTiO <br /> f PRIOR TO G UTING D' FINAL ;NSPECUON. <br /> SIGNED TITLE <br /> DRAW PZ'T PLAN 'ON REVERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED;:BY <br /> ADDITIONAL COMNIENTS: I: WPE IN INSPECTION �7PHASE II OUT INSPECTIONDATE — '/INSPECTION BY DATE INSPECTION B <br /> I` 3/76 2M <br /> E H 1426 Rev. 1--74 - -- <br />