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: C 1 4d � <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> or.. USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - o��° <br /> THIS. PERMIT .EXPIRES 1.YEAR FROM DATE ISSUED Date Issued s_ <br /> 6� Triplicate) <br /> (Complete In <br /> :Applicdtion struct <br /> is hereby made to the San Joaquin Localationiatmade in compliance rict for a permit twithaSan Joaquin <br /> `and/or. install the work herein described. This applic <br /> County Ordinance No-,1862 and <br /> San Joaquin.Loca -Health District. <br /> Rules and Regulations Of- the <br /> P7 Z7 `CENSUS-TRACT <br /> JOB.,ADDRESS/LOCATION <br /> �� �...�.� � Phone <br /> Owners Name / <br /> City �. <br /> x <br /> Address <br /> License, # / Phone. <br /> Contractor's Dame 4o 00 <br /> TYPE OF WORK (Check): NEW WELL I�T DEEPEN 1_7 'RECONDITION /7�EREPLACION EMEN� <br /> PUMP INSTALLATION / PUMP REPAIR ff/ <br /> Other / / <br /> `� _ PIT PRIVY _ ; <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES _ OTHER <br /> SEWAGEfDISPOSAL FIELD CESSPOOL/SEEPAGE PIT ^ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �l <br /> ..INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. o€ Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing + <br /> E 'IrrigationGravel Pack Depth of Grout Seal <br /> `Cathodic .Protection + .r� Rotary. TYPa of Grout <br /> Disposal Other Other Information . <br /> ^GeophysicalSurface Seal Installed BY: <br /> Contractor �' �' "'`" <br /> PUMP INSTALLATION: H.P. <br /> I _ `Type of Pump u mss. <br /> PUMP REPLACEMENT: /. State Work Done <br /> / <br /> e. <br /> PUMP '.REPAIR: ; �' ' ` State Work Done <br /> Approximate Depth <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> . : <br /> I Hereby agree to comply with all lawrict <br /> s and regulations owellecvnstruction: oWithin' F'IFTEENtDAYS <br /> and the State of California- pertaining to or regulating <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 GROUTING AND A FINAL INS P N. TLE <br /> k SIGNED, D 'PLOT PLAN ON SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> Pllkm I DATE <br /> _APPLICATION ACCEPTED BY <br /> s ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> 5 PHASE-:II GROUT INSPECTION DATE ' <br /> INSPECTION BY DATE INSPECTION: BY / <br /> �. W%� <br /> 1-74 2M <br /> E H 1426 Rev.111-74 <br />