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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> F0_St5FFxC_ E USE,: 1601 E. Hazelton Ave. , ,Stockton, Calif. , <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> :113 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' [ (Complete In Triplicate) <br /> Application is tereby 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 an the R�es and Regulatio s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ' y / CENSUS TRACT <br /> Owner's Name t ✓ <br /> Phone <br /> Address l City <br /> Contractor's Name <br /> License/4a3!25 Phoned <br /> y <br /> � 1 <br />'TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION,/-7 DESTRUCTION /-7� <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,. ..,, PIT PRIVY. <br /> SEWAGE �DISPOSAL FIELD CESSPOOL/SdPAGE4IT OTHER - - <br /> PROPERTY LINE-'PRIVATE •DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial F Cable Tool Dia. of Well Excavation �4 <br /> Domestic/private ` *t. Drilled Dia. `of Well Casing <br /> Domestic/public # Driven Gauge of Casing <br /> Irrigation t Gravel Pack"' ""= Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information _ <br /> Geophysical w. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1 >. <br />� /f� L 1 <br /> PUMP�:REPAIR-: = --�- --State-Work-Done (�� � - -_ — <br /> DESTRUCTION 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 istrict <br /> and the State: of'California pertaining to or regulating well "'construction. Within FIFTEEN DAYS <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 INSPECTION. <br /> I` SIGNED'; TITLE =- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I (� <br /> APPLICATION ACCEPTED BY ^+\ \ ,C� �1 _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PTJA&E aiLl/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY BATE <br /> X1177 - <br /> * E H1,426 Rev. 1-74 - <br />