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70i OFFICE USE: 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 /> Ii . � a . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -,ISSUED <br /> # (Complete In �Triplicate)3 Date Issued ?{! <br /> Appiicatian is hereby made to the Batt Joaquin Local Health>Disttict for a pelt to'con J <br /> and/or install the work herein described. This application is.:made in;compliance with Saruct <br /> County Ordinance No. 1862 and the Rules and Regulations�of. the San Joaquin.-:Local <br /> M i 2. t-'7Sq J�-E_ �ov� " n ,Toaqui: <br /> Health District, <br /> JOB ADDRESS/LOCATION 10 7-.Zop_z-c- <br /> A i <br /> CENSUS TRACT <br /> Owner's Name <br /> Address' r Phone <br /> Contractor's Name City �. <br /> 3 <br /> License' # Phone <br /> TYPE OF WORK -(Check)':`--NEW-WELL_/? DEEPEN _ - - <br /> _/ p RECONDITION /? DESTRUCTION <br /> C Ottt Ier ALLA IaN I I PUMP REPAIR / / PUMP REPLACEMENT ' <br /> DISTANCE TO NEAREST; SEPTIG TANK _ <br /> SEWER LINES E PITPRIVY <br />� SEWAGE DISPOSAL FIELD -I_ <br /> CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE, - PRIVATE DOMESTIC WELL f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS <br /> f _ Domestic/private?` Drilled Dia. of We11 Excavation <br /> Domestic/public Dia.- of Well>Casing <br /> Irrigation --== given Gauge of Casing <br /> Cathodic-Protection - --- Gravel Pack Depth of Grout Seal <br /> -__Disposal -_�ZZ: Rotary �'ypewuf Groci� <br /> __Geophysical Other Other Information <br /> Surface Seal4stalled B <br /> PUMP INSTALLATION:;-� ' <br /> Coactor <br /> Type of Pump r <br /> ` H.P. <br /> PUMP RREPLACEMEjff; <br /> ,/� State Work Do <br /> D�T,ry <br /> ne , <br /> r f <br /> State�--�;r,_. <br /> r. Work Done <br /> ES�TRUCTION OF WELL; <br /> '_'Well <br /> Diameter 3 �' <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San .Taaquin 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 D <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.knowled a and belief, District a <br /> PRIOR TO GROU G AND A F g I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED SPECTION. <br /> TI <br /> (DRAW PLOT PLAN ON REVERSETLE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS: DATE _ �• <br /> PHASE II GROUT INSPECTION _ <br /> INSPECTION BY DATEP INAL INSPECTION <br /> INSPECTION B DATE <br /> E H 1426 <br /> Rev. 1--74 <br />