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"FOE OFFICE USE: k� SAN JOAQUIN-LOCAL HEALTH. DISTRICT ~ <br /> 1601 E. Hazelton Ave. , <br /> Telephone: Stockton, Calif. <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> HIS P . <br /> ERMIT EXPIRES l YEAR FROM DATE ,ISSUED <br /> ' Application is her eb ± (Complete In Triplicate) Date Issued <br /> Y made `to the San Td. Th Local Health District for a <br /> permit and/or install the work heroin described. <br /> County Ordinance N l$. This application is made in compliancetwithnSan Jt <br /> a - t ules and Regulations of, the San Joaquin Local <br /> JOB ADDRESS oaquin <br /> /LOCATION 1 Health District. <br /> Owner's Name CENSUS TRACT <br /> Address ;�. �, Phone <br /> Contractor's Name t City <br /> License #4�j/Phone ` 021 <br /> TYPE OF WORK ,,/ _ <br /> (Check) : NEVI Y WELL <br /> DEEPEN —PUMP _ <br /> PUMP INSTALLATION/ / PUMP REPAIR /-7 DESTRUCTION /-7 <br /> Other './ / 7. PUMP REPLACEMENT /-7 . <br /> DISTANCE TO NEAREST: A <br /> SEPTIC iTANK <br /> SEWER LINES - PIT PRIVY <br /> ,y SEWAGE �DISPOSAFIELD _ ' <br /> PROPERTY LINE - PRIVATE MESTIC W /SEEPAGE PTT <br /> INTENDED USE 3 ELL OTHER <br /> Industrial. TYPE OF WELL PUBLIC DOMESTIC WELL <br /> Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of Well Excavation <br /> Domestic/public . ___--�r�. Drilled Dia. of Well Casing / <br /> /Pub.�ic �� Driven <br /> Irrigation F "� Gravel Pack Gauge of Casing <br /> Cathodic Protection Depth Of Grout Seal �} <br /> Disposal --.�! Rotary <br /> Other Type of Grout. . 0� <br />� Geophysical .__ <br /> -_ _� Other Information,' <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor �1 <br /> _ --r <br /> Type of Pump <br />'UMP REPLACEMENT: H.P. <br /> / / Stat e.t Work Done a- <br />'UMP .REPAIR: ' <br /> / State Work Done <br /> ES•TRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ---_� <br /> hereby agree to comply with all laws and regulations of .the San Joaquin Local Health lid the State of California pertaining to or regulating well 'constructfon. Within FIFTEEN Eter completion of my work on a new well, I will furnish the San Joaquin Local H lIF District <br /> ELL DRILLERS REPORT of the well and notify them before putting the -well in use. EEN DAYS <br /> iformation is true Health District a <br /> to the best, of my- knowledge and belief, The above <br />'.IOR TO GROUT G AND A FIN IN ECT ION. I WILL CALL FOR A GROUT INSPECTION <br />:GNED <br /> TITLE <br /> DRAW PI, T' PLAN 'ON REVERSE SIDE) 4 <br />:ASE I FO TMENT USE NLY' <br /> PLICATION ACCEPTED BY <br /> DITIONAL COMMENTS: wv' DATE <br /> F <br /> PHASE II GROUT INSPECTIOHA <br /> N <br /> SPECTION BY DATE { PSE II /FIN INSPECTION i <br /> INSP'CTION <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />