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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEfOFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: ,.. (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _�q f' <br /> . 7� <br /> THIS PERMIT EXPIRES 1 ?YEAR, FROM DATE .ISSUED Date Issued E7-e- 7� <br /> y¢ (Complete In 'Triplicate)., <br /> Application is hereby made to the San Joaquin Local Health District for a ' ermit .to c <br /> and/or install the,*work herein described. This applicatior:i:is p Construct <br /> County Ordinance No: 1$62 and the Rules ,and Regulations of the Sane)Joaquin Local-Health pliance with SDistrict. <br /> JOB ADDRESS/LOCATION , C <br /> s - CENSUS ZCT <br /> Owner's Name <br /> a Phone <br /> Address <br /> City w i <br /> Contractor's Name ` <br /> License # ��.." <br /> _ l YJ. Phone <br /> TYPE OF. WORK (Check): NEW WELL /`TDEEPEN /7 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION <br /> Other / PUMP REPAIR / : .PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE 'DISPOSAL FIELD PIT PRIVY G1 <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL M <br /> INTENDED USE' TYPE OF WELL <br /> Industrial CONSTRUCTION <br /> ..SPECIFICATIONS <br /> Cable Tool SPE <br /> Well Excavation <br /> _ Domestic/private E Drilled <br /> Domestic/public Dia. of Well Casing <br /> G Irrigation --.. Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary 'Type of Grout <br /> Disposal . <br /> 1 Geophysical Other Other Information <br /> Surface Seal Instal3ed B <br /> 4 1 <br /> PUMP INSTALLATION: Contractor. <br /> ' Type of PumpA* lid-/,& �.' <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done [ ! <br /> P <br /> UMP''.REPAIR: /?State• <br /> Work Done -�� �. ,� ry '��� "-L <br /> E5TRUCTION OF WELL: Well Diametery� <br /> 'Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San 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_wel1 in-use-4 The above <br /> information is true to the.best-of my.kniowle and lief. <br /> PRIOR TO UTING AND A FINAL INSPECTZ N; I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED - <br /> ' <br /> TLE _C ' <br /> D W OT P ON RSE SIDE <br /> PHASE I <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE• r <br /> PHA51 I GROUT INSPECTION P SEI FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION- BY <br /> _.. DATE L <br /> E H 1426 Rev. 1-74 . - - <br />