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FOZ.OFFICE USE: kw)L SAN JOAQUIN LOCAL 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 I YEAR FROM <br /> DATE 'ISSUED <br /> In Tr <br /> AgnlicaCion is hereby made to the San(Complete oaquin Laval Iealth licate) Date Issued <br /> acid/or install the work herein described. This application Distmade inr a permit to construct <br /> Jo <br /> County Ordinance No. 1862 and the Rules and Regulations og the San J compliants with San Joaquin <br /> Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � <br /> CENSUS TRACT - <br /> Owner's Name <br /> Phone ' <br /> Address 501 <br /> Contractor's Name City .- <br /> License <br /> ity 'License # <br /> vne _ 7� <br /> TYPE OF WORK (Check): NEW WELL ' <br /> /„T DEEPEN '/-7 RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR ./TR_.�PUMP REPLACEMENT <br /> Other /% r.-T <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT— <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL~—' <br /> INTENDED USE TYPE „OF WELL <br />�- Industrial CONSTRUCTION SPECIFICATIONS <br /> Dotrmestic Cable Tool Dia. of 'Well Excavation <br /> /Private Drilled <br /> Domestic/public Dia. of Well Casing <br /> 'Irrigation Driven Gauge of Casing <br /> r' `�� G�8ve1 P�Gk� � `�` <br /> Cathodic Protection'. Depth of Grout Seal <br /> Disposal —,.`. Rotary Type of Grout <br /> Geophysical ----. Other Other information <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION Contractor <br /> Type of114/ <br /> Pump �`r <br /> sti r / H.P. <br /> PUMP REPLACEMENT• • <br /> State Work Done <br /> PUMP :REPAIR: <br /> /�/ State Work Done <br />!ES•TRUCTION OF WELL; . Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health-red the State of California on a new w to or regulating well ''construction. Within FIFTEEN DAYS <br /> District <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting. the..well. .in.use... The above <br /> reformation is true to the.best of-my.knowl.ed e <br /> kIOR TO GR[]UTING AND A VINAL INSPE.-CTIA g aad-belief. I WILL CALL VAD A GROUT INSPECTION <br /> t . <br /> f -ITLE <br /> DRAW L PL - ON REV SE SIDE ' <br /> RASE I DEPARTMENT USE ONLY <br /> TPLICATIQN ACCEPTED BY <br />)DITIONAL pOMMENTS: DATE <br /> PHASE II GROUT I CTTON . <br /> iSPECTION BY DATE PHAS III F NAL INSPECTION <br /> INSPECTION BY . DATE <br /> E,H 1426 Rev. ` <br />