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_ Co W"P Ai SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOErOFFiCE USE: Telephone: (209) 466 -6781 <br /> �7a P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ante Issued 3-7-. <br /> (Complete In Triplicate) <br /> ct <br /> Application is hereby made J'th. San Joaquin Local Health District fo in compl agcetwith San Joaquin <br /> and/or <br /> application is uLade <br /> and/ox install the work herein described. This <br /> County Ordinance No. 1562 and. the Rules and Regulations of the San�,�oaquiza Local Health District. <br /> � � O a 1'r, � CENSUS TRACT <br /> JOB ADDRESS/LOCATION Ll- .i <br /> Phone <br /> Owner a s Name City 05� <br /> Address <br /> License # !�Phone <br /> Contractor s Name <br /> ON <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /=T RECONDITION I fiWP�EREPLACIEMEN�fT <br /> PUMP ,;INSTALLATION / / PUMP REPAIR <br /> k Other <br /> DISTANCE To NEAREST: SEPTIC TANK SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHER <br /> PROPERTY LINE w PRIVATE DOMESTIC WELLCOESTIC WELL <br /> NSTRUC ION SPECIFICATIONS <br /> INTENDED USE .TYPE OF WELL <br /> Instrial i Cable Tool Dia. of Well <br /> Industrial Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> e_ Domestic/public [ Driven Gauge of Casing <br /> P Irrigation E1 Gravel Pack Depth of Grout Seal <br /> Type of <br /> Cathodic Protection Rotary Go <br /> t , Disposal Other Other information <br /> Grout <br /> E . <br /> Surf ace Seal Installed B <br /> Geophysical <br /> 1 PUMP INSTALLATION., Contractor H.P. <br /> Typefi` of Pump <br /> 4 PUMP REPLACEMENT: / /i State Work Done <br /> . PUMP `.REPAIR: 10 <br /> State Work-Done <br /> 'Approximate Depth <br /> ES:TRUCTION OF WELL: Well Diameter <br /> ^ <br /> Describe Material and Procedure <br /> Dis <br /> rict <br /> I hereby agree to com 1 with all laws and reelu3atin °welleconstructioa San oaquin Ldcam <br /> Within aFIFTEEN tDAYS. <br /> � p y ; <br /> and the State of California pertaining to or g 5 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health <br /> haboverict a <br /> WELL DRILLERS REPORT of tkie well and notify them before putting. the..well in use.. <br /> i information is true to the.beat ofmm know dge an elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANIS A FINAL INSP N. TLE <br /> SIGNED W PLOT P ON RE4RSE'SIDE + <br /> FOR DEPARTMENT USE ONLY <br /> 4 PHASE I -- ((,eCJ' DATE If <br /> r APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: a P E I FINAL IN PECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 7 <br /> INSPECTION BY 0. DATE <br /> 1-74 2M <br /> 4 E H 1426 Rev. 144 <br />