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_. ------------- <br /> SAN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$jOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �i <br /> THIS PERMIT EXPIRES 1 YEAR FROM RATE ISSUED Date Issued <br /> 4� (Complete In Triplicate) <br /> Application is 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 gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � CENSUS TRACT <br /> is <br /> Owner's Names Phone i <br /> i <br /> Address �v4:�t City <br /> Contractor's Name IMMNQS BROS, MTTLTNQ License # 290813 Phone 522-1031 <br /> s.- <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/? RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other '/� <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' \ PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial i Cable Tool Dia. of Well Excavation •� (�j,� <br /> /Domestic/private +''—Drilled r Dia. -of-,-Well Casing <br /> Domestic/public iDriven Gauge of Casing- <br /> Irrigation ;4i Gravel Pack Depth of Grout Seal 6--a <br /> Cathodic Protection I _�Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical w_-._ Surface Seal Installed B e <br /> T <br /> PUMP INSTALLATION: k ° <br /> Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMp'REPLACEMEN'T: j/ / State Work Done <br /> PUMP .REPAIR• /- Work-Done - <br /> = _ . . �.-� State�� ms_. <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 a �. <br /> WELL DRILLERS REPORT 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 FORA GROUT INSPECTION <br /> PRIOR. TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> � . DRAW PLOT PLAN ON REVERSE SIDE A <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE I 4 r 1 <br /> APPLICATION ACCEPTED BY <br /> DATEr- <br /> ADDITIONAL COMMENTS: - <br /> 7PSEI GR INSPECTION P SE I FINAL INSPECTION <br /> INSPECTION BY DATE -'� INSPECTION BYDATE <br /> E H 1426 , Rev. 1.74 1--74 2M i <br />