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•r, « ' � O SAN JOAQUIN LOCAL HEALTH-DISTRICT ■0 <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. 1`� ' <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 yarn Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is :Wade in compliance with San Joaquin; <br /> County Ordinance No. 1862 aannd� the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION ," "" `;;r CLNSUs CT <br /> Owner P s Name <br /> Address L- <br /> Contractor Ngv4f License # Phone <br /> TYPE OF WORK' (Check): NEW WELL/'P7DEEPEN ./-7 RECONDITION /7 DESTRUCTION f-7 ` <br /> PUMP INSTALLATION IgPUMP REPAIR 1—/—PUMP REPLACEMENT /-7 <br /> Other <br /> O <br /> DISTANCE TO NEAREST': SEPTIC TANK SEWER LINES PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v, <br /> INTENDED USE 4- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial " ` Cable Tool, Dia. of Well Excavation S <br /> lostic/private _ Drilled Dia. of Well Casing S <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal .3`C) <br /> Cathodic Protection �(t Rotary Type of Grout' [-ozme* <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: :S.tate,�Work;Done <br /> E � G <br /> ES;TRUCTION OF WELL: Well Diameter i Approximate Depth <br /> Describe Material and Procedure µ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> aadthe 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 /> WELLDRILLERS NPORT of the well and notify them before putting-the-well in.use. The above <br /> inf � <br /> gfm�",t•,`ion- is true to .ttie best of my.knowledge and belief. I -WILL CALL FOR 'A -GROUT INSPECTION <br /> PRIOR-ITO GROUTING Mp_,AXINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION _ . � PHASE III v NAL INSPECTIO19 <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> f, <br /> E H 1426 Rev. 1-74 �� 1-74. 2M <br />