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Coe <br /> SAN JOA UIN LOCAL <br /> FOF�:OFFICE USE: � HEALTH DISTRICT <br /> 1601 E. Hazelton Ave.-, Stockton, Calif. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,. <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 San Joaquin <br /> County Ordinance No. 1862 Andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � <br /> , . CENSUS TRACT <br /> Owner's Name f <br /> Phone 4 <br /> Address <br /> CityLlzm <br /> Contractor's Name } <br /> License # Phone .-o <br /> TYPE :OF WORK (Check): NEW WELL L_7 DEEPEN '/," RECONDITION /_7 DESTRUCTION /-7 . <br /> PUMP INSTALLATION '/ / PUMP REPAIR I-7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ FIT PRIVY : 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE-=-PRIVATE"DOMESTIC' WELL-:"r <br /> OTHER <br /> Q <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cab Tool Dia. of Well Excavation <br /> Domestic/private s Drilled Dia. of Well Casing, ,r <br /> Domestic/public f Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' Rotarq Type of Grout <br /> Geophysical . . . <br /> Disposal r Other Other Information <br /> � <br /> Surface Seal Installed B ., <br /> PUMP INSTALLATION: . <br /> Contractor IJ <br /> Type ;of !Pump H.F. <br /> PUMP REPLACEMENT: %/ St ate Work Done "" ;. <br /> t s <br /> PUMP 'REPAIR: /7 State Work Done V <br />)ES,TRUCTION,OF WELL: __-',Well ' <br /> Well Diameters � � Approximate Depth <br /> Describe Material a d'Procedure '. p <br /> ' P Y' <br /> E herebylagree :to co�m T with all laws andfregulations of the%San Joaquin Local Health District <br /> knd the State of California pertaining to-'or regulating well '�co sCruction. Within FIFTEEN DAYS <br /> Ifter completion �of�my work on anew well, I will furnish the San Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the well and notify thein'l 6fo�e`putting. the .well. in.use.... The above <br /> Lnformation is true to the•best`.of. my knowledge,and belief. a I•WILL° CAI;L OR A GROUT INSPECTION <br /> RIOR TO GR TING AN A FIN NS ION. ` <br /> UUMIJ <br /> TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> PPF CIL ATION ACCEPTED BY <br /> Aft)L— <br /> -1 ' ' DATE ' - �°�� , <br /> ADDITIONAL COMMENTS: h -- - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE— _ INSPECTION BYDATE Z <br /> .E H 1426 Rev. 1-74 ' R: ^ <br />