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SAN JOAQUIN LOCA. HEALTH DISTRICT ' <br /> ;FOh.OFFICE USE: 3.601 E. Hazeltofi Ave:, Stockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� 3a8ry <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued <br /> %I (complete In Triplicate) <br /> Application is hereby made t6 the San Joaquin Local Health District for a permit to construct <br /> sand/or install the work herein described. - This application is.made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT , <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> �v ease .# . Phone p J <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN/? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR'/_7 PUMP REPLACEMENT /—T <br /> Other E/ -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY: LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL <br /> INTENDED_USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> ustrial 4 Cable Tool. Dia. of Well Excavation kk <br /> l Domestic/private Drilled Dia. of Well. Casing �� � <br /> Domestic/public : Driven Gaugeof Casng <br /> i <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection . rotary Type of Grout <br /> Disposal �� Other Other Information <br /> Geophysical r �� Surface Seal Installed B 1, <br /> PUMP INSTALLATION. Contractor " <br /> Type of1Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done d' <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - <br /> Approximate Depth <br /> DescribeMaterial 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' peitaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work onka 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 CAL.L 'FOR A 'GROUT INSPECTION <br />'RIOR TO OUTING AND A FINAL I PECTION. <br /> SIGNED TITLEA <br /> W PLOT 'PLAN ON REVERSE SIDE <br />'HAS E I FOR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY DATE <br />►DDITIONAL COMMENTS: d 76 Velez lu ' <br /> PHASE II GROUT INSVECTION <br /> HAAE III INAL INSPECTION <br /> INSPECTION BY DATE.; INSPL�CTION BY DATE <br /> E H 1426 Rev. 1-74 <br />