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n �.4 <br /> SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT <br /> FOE.OFFICE USE: 1601 E'. Hazelton Ave. , Stockton, Calif. <br /> s4 Telephone: (20g) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE -ISSUED Date Issued - -76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /> Count Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION a rCa.d.0 CENSUS TRACT 226 s Q3 <br /> Owner's Name a�a Phone <br /> Address ' / <br /> City ' & nl&r' <br /> Contractor's Name r w.. zd License # <br /> hone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPENRECONDITION /7 DESTRUCTION <br /> L� <br /> PUMP. INSTALLATION 17 ALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other E7 _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL rn <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/ private Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical- Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor -- . . <br /> 'Ype of Pump .r. H.P. . <br /> PUMP REPLACEMENT: . /_7 State Work Done <br /> PUMP °REPAIR: / / State Work Done , <br /> DES;TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <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 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G 'AND A FINAL INSPECTION. <br /> SIGNED <br /> i' (DRAW PLOT PLAN 6N REVERSf'r S IDE <br /> PHASE I IPORIDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II P P I iNAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATEr <br /> E H 1426 Rev. 1-74 <br />