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FOF OFFICE USE; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEII �c <br /> Date IssuedIn Triplica ) - / <br /> Application is hereby made to the San (JoaquineLo a2 HealthtDistrict for a permit t <br /> and/or install the work herein described. This a P o construct <br /> j County Ordinance No. 18b2 and the Rules and Regulations SanJouinpLocace with San Joaquin <br /> q l Health District. <br /> JO$ ADDRESSfLOCATION <br /> r lyl � pNe�l �!/iJ eC)d <br /> CENSUS TRACT <br /> Owner's Name -- <br /> Phone ` <br /> Address . <br /> City <br />'. Contractor's License # <br /> Xione 9 <br /> 4 : <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPS_ <br /> N /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT .� <br /> Other /� -- <br /> DISTANCE TONEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT— OTHER <br /> OTHER <br /> PROPERTY LINE - PRIVAT <br /> INTENDED USE E DOMESTIC WELL_ PUBLIC DOMES <br /> TYPE OF WELL TIC WELL. <br /> Industrial CONSTRUCTION'RUCTION SPECIFICATIONS <br /> Cable Tool Dia.. of Well Excavation <br /> Domestic/private Drilled <br /> Domestic/public Dia• of Well Casing <br /> Irrigation Driven Gauge of Casing F <br /> Gravel Pack Depth of Grout Seal CF <br /> Cathodic Protection Rotary Type �_~ <br /> Disposal of Grout <br /> r_J' <br /> Geophysical <br /> Other Other Information <br /> --------- <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P, 2-1- <br /> L ` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ^ <br />)ES__. TRUCTION OF WELL: Well Diameter T <br /> Describe Material and Procedure Approximate Depth _ <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and otify them before putting the well in use. The above <br /> RIOR TO G <br /> nformation true to the best o my know dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> T G AND A F N L <br /> ' INS , <br /> IGNED C N <br /> TITLE ' <br /> (DRA LOT PLAN ON REVERSE SIDE) <br /> RASE 1 FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY kL <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> VSPECTION $Y DATE PHA E_ III/FINAL INSPECTION <br /> INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 <br />