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FOF OFF CE USE: SAN JOAQUIN LOCAL-'HEALTH DISTRICT <br /> 1601 E. Hazelton .Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 �h <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -V' 7 /d <br /> THIS PERMIT EXPIRES I, YEAR FROM DATE ISSUED <br /> Date Issued <br /> '- � � (Complete In Triplicate) <br /> Application is hereby made io the San Joaquin Local Health District for a permit to construct <br /> and/or install the .work herein described. This application .is made in compliance with San Joaquin <br /> Count Ordinance No. „1-862. a d, the Rules and Regulations of the San Joaquin Local Health District. <br /> � �.Wit, �.._ �.� <br /> JOB ADDRESS/LOCATION / <br /> ... 96''''v,c-e dam` CENSiJS TRACT <br /> Owner's Name D <br /> .Phone <br /> Address <br /> City <br /> ' Contractor's Name .� � <br /> License # <br /> _!I ? one <br /> f TYPE OF WORK (Check) : NEW,WELL � ° <br /> / DEEPEN I I RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION L/ PUMP REPAIR PUMP REPLACEMENT /_ j <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PTT STICWELL <br /> 4 <br /> PROPERTY LINE _ PRIVATE DOMEOT <br /> STIC WELL PUBLIC DOME <br /> INTENDED USE Tx-rt OF WELL <br /> Industrial CONSTRUCTION SPECIFTCATTONS �u <br /> Cable Tool <br /> Dia. <br /> of Well Excavation <br /> /public <br /> 1 <br /> Domestic Dia. of Well Casing v� <br /> ! Of <br /> of Casing Irrigation Driven Gauge $ :, '� <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal l Other <br /> Geophysical <br /> ” Other Information <br /> � - Surface Seal Installed B : <br /> PUMP INSTALLATION: <br /> Contractor � <br /> Type of Pump a w <br /> P. <br /> PUMP REPLACEMENT: `—" <br /> Stafe Work Done <br /> PUMP .REPAIR: <br /> / State Work Done <br /> UES•TRUCTION OF WELL: Well Diameter r. <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local <br /> and the State of California pertaining to or regulating well "construction. Withiinalth FIFTEENtDAYS t <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a f <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 owled elief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GR TING AND A FINAL S k <br /> i TGNED TNCT <br /> TLE <br /> t (D W OT LAN ON RE RSE SIDE) <br />'HASE I FOR DEPARTMENT USE ONLY A <br /> APPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: - DATE <br /> NSPECTION BY <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BYE <br /> DATE 3 3 a J <br /> i <br /> E H 1426 Rev. - I-74 0� nam <br />