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400 <br /> �a v`` 4SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE FACE USE: 1601 E. Hazelton Ave. ., Stockton, Calif. 4G <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. 171�-177(s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Bate Issues�C <br /> Application is her (Complete In Triplicate) <br /> eby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. .This application is made in comp <br /> County Ordinance No. 1862 and the Rules and Regulation' liance .with San Joaquin <br /> s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> -- <br /> Owner's Name ��i�i v " <br /> Phone <br /> Address <br /> City <br /> Contractor's Name License hone iiy -- s <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN ' .. i <br /> _/_/ RECONDITION /_/ BESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other <br /> r <br />-DIST LNUE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V) <br /> Industrial Cable Tool Dia, of Well Excavation ` <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven <br /> �.. Gauge of Casing <br /> _�- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other <br /> yp <br /> ther Other Information <br /> Geophysical Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r f <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: S � r <br /> tate Work Done �- <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i <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 we11 `coxistruction. 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 /> PRIOR TO OUTING D A FINAL IN'rmation is true to the best o:PE f\ y owledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIO <br /> SIGNE <br /> ovOTITLE _ <br /> (DRAW L PLAN ON FRSE SIDE) <br /> PHASE I FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: , ,DATE ey <br /> PHASE II GROUT INSPECTION P / IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE p 7 <br /> E H 1426 <br /> Rev. - 1-74 �� 7 2M e <br />