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OF <br /> FOR OF JOAQUIN LOCAL HEALTH DISTRICT <br />` . FICE USE: <br /> V16O <br /> 1 E. Hazelton,Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a. permit to construct <br /> and/or install the work herein described. This application is made in compliance with Sad 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 /> f , Phone ldC <br /> Address _ 1 <br /> City 7c�I ' r � 4 <br /> Contractor's Name Y <br /> •'' License :# _ -., <br /> ; hone ;1 <br /> TYPE OF WORK (Cheek); NEW WELL [ DEEPEN ,/ RECONDITION TRY „ Y T <br /> PUMP INSTALLATION PUMP REPAIR DESTRUCTION /� <br /> /� PUMPREPLACEMENT 17 <br /> Other %i/ . <br /> DISTANCE TO NEAREST: SEPTIC TANKi <br /> � � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIS OTR <br /> PROPERTY <br /> INTENDED USE LINE ..PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> TYPE'OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable-Tool -«- -. Dia. -of--Well -•Excavation <br /> 17 <br /> Domestic/private Drilled Dia. of Well Casin <br /> Domestic/public <br /> :Driven Gauge of Casing O <br /> Irrigation Gravel Pack Depth ,of GroutlSe l <br /> Cathodic Protection Rotar I <br /> Disposal Y . Type of Grout <br /> Other Other Inform, on <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor' <br /> Type .of Pump r <br /> H.P; ' <br /> PUMP REP LACEMENT: • <br /> State Work Done <br /> PUMP :REPAIR: / % State Work� . <br /> _ Done <br /> --_ <br /> IES•TRUCTION OF WELL Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> L hereby agree to comply with alI laws and regulations of the San Joaquin Local Health District ' <br /> and the State of California pertaining to or regulating well "construction. i `W3 thin FIFTEEN DAYS <br /> after completion of my work on•a new well,.• I_wi11 furnishhe.w5an Joaquin---Local Health District a <br /> BELL DRILLERS REPORT of the-well and notify them before putting the.-well. in'use.... .The above f <br /> Lnformation is true to 'the,best-of my..knowledge and belief. I WILL CALL FOR'A GROUT INSPECTION <br /> RIOR TO TING AND A F N PECTION. <br /> iIGNED ..t.., � <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID f <br />'RASE I FOR DEPARTMENT USE ONLY <br /> J'I'�L A ION ACCEPTED BY -T <br /> DDITIONAL COMMENTS•. <br /> DATE�I�ZJ�� <br /> PHASE II GROUT INSPFINAL <br /> ECTION PHASE i I INSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> ,... DATE -7 <br /> F <br /> E H 1426 <br /> Rev. 1-74 <br />