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.l <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE" USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .I Date Issued 1--1-1-0:26 <br /> (Complete In Triplicate) <br /> Application is hereby wade to the San Joaquin Local Health District for al�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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONa , CENSUS TRACT 1 <br /> II' <br /> Owner's Name P� - "' Phone <br /> t <br /> Address Cityk <br /> Contractor's Name License # 'i Phone <br /> ,M <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/ / RECONDITION /_/ DESTRUCTION J <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/SEEPAGE PIT ii OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br />! Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done �}V) <br /> P <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 100 <br /> Des ri a Material and Procedure <br /> V <br /> I hereby agree to comply with all aaws aAd regulations of the gan Joaquin Local Health District <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 /> f information is true to the best of my. knowledge and belief. I WILL CALL'.FOR A GROUT INSPECTION ' <br /> PRIOR TO GRO T G ANP A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W .PL T' PLAN 'ON RE FRSE SIDE ;; I' " <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I I� <br />! APPLICATION ACCEPTED BY ---- M DATE <br /> ADDITIONAL COMMENTS: 6 <br /> PHASE II GROUT INSPECTION PHASE III iFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �� / <br />