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SAN JOAQUINkLOCAL'HEALTH DISTRICTFOR +OFFICE USE: 1601 E. Hazelton."Ave:;; Stockton, Calif. <br /> ` <br /> Telephone: (,-.!(209Y 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 14YEAR�"FROM DATE ISSUED Date Issued - <br /> .r >'° k (Complete ,:In.Triplicate) <br /> I Application is hereby made -to the San Joaquin. Local.Flealth District for a permit to construct <br /> and/or,install the.work herein described, . This application is trade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Mules ".and,-_Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,:.,`l 01 <br /> CENSUS TRACT t " <br /> Owner°s Name <br /> �� Ocdxroo, <br /> Address'-- <br /> City <br /> Contractor's Name 's License <br /> TYPE OF WORK (Check) ; NEW WELL "/ DEEPENRECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATIQN UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / --- <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER" LINES PIT PRIVY <br /> SEWAGE{ DISPO AL FIELD CESSPOOL/SEEPAGE PITOR <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT," PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE -6F—WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` Cable Tool Dia. .of Well Excavation <br /> Domestic/private Drilled Dia:- of- Well Casing <br /> - Domestic/public ii Driven Gauge of Casing <br /> Irrigation }i� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ! Rotary Type of Grout <br /> Disposal i OtherOther Information <br /> ��� . - - <br /> Geophysical ' Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / ./ State Work Done <br />-PUMP=:REPAIR: ..� Work' Done' <br /> '/� State -�� <br /> ES-7RUCTION OF WELL: Well Diameter _ Y <br /> Approximate Depth <br /> ' Describe Material'and Procedure <br /> r <br /> i <br /> 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 a <br /> WELL DRILLERS REPORT the well and notify them before Putting-the.-well use.. The above , <br /> information is tr to the-best.of my. owledge and belief. I WILL <br /> PRIOR TO ;I R A 'GROUT INSPECTION 'i <br /> SIGNED i TITL <br /> - t RAW PLOT PLAN ON REVERSE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY try <br /> APPLICATION ACCEPTED BY " " DATE G <br /> ADDITIONAL COMMENTS: <br /> PHASE .II GROUT INPE ON PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BY ._� DATE "— <br /> } E H 1426 Rev. 1-74 <br />