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s <br /> D SAN JOAQUIN LOCAL".HEALTH DISTRICT <br /> FOH�Oll <br /> ICE USE: 1601 E. Hazelton .Ave-. Stockton 'Calif. <br /> t Telephone: _:1(209) 4660-6781_ <br /> APPLICATION FOR WELL CONSTRUCTION Oft PUMP PERMIT Permit No. �S <br /> THIS PERMIT EXPIRES 1 .YEAR''FROM DATE-.ISSUED Date Issued 'aa: Z <br /> (Complete,ln Triplicate) •. . <br /> Application is hereby made to; the San Joaquiu..Local,filealth ,District for a permit to construct <br /> and/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 ., ... O0L - CENSUS TRACT <br /> Owner°s Name P%tl Phone <br /> �,�-< _ <br /> Address "' . _ �.' 1�� •/�! - -. � City _ <br /> License1 3 hone ( <br /> Contractor's .Name <br /> w40� <br /> TYPE OF- WORK (Check): NEW WELL /� DEEPEN -/ . RECONDITION /? DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP .REPLACEMENT <br /> Other 1/7' , <br /> f <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i ►. Cable Tool Dia. •of Well Excavation { <br /> Domestic/private 4 Drilled Dia: of Well Casing # <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation t Gravel,Pack . Depth of Grout Seal <br /> I Cathodic Protection 4 Rotary Type-of Grout <br /> 5 Disposal I Other Other, Information <br /> Geophysical _ Surface Seal Installed BY: <br /> 4 <br /> PUMP INSTALLATION Contractor - <br /> L...I i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done . 7 <br /> I PUMP .REPAIR:'- /=7" State Work Done - <br /> pES'T.RUCTION OF WELL: Well Diameter 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 /> s after completion of my worklon 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 hest of. myVwl an elief: I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G ING AND A FINAL INSPE <br /> SIGNED i c-e, • TLE <br /> (D LOT ON'RE RSE SIDE <br /> �1 OR DEPARTMENT USE ONLY <br /> PHASE I 1 r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> -' PHASE II GROUT. INSPECTION PHAS I/FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � 4 E H 1426 Rev. 1-74 1-74 2M , <br />