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{ S <br /> AN AN U LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE; 1601 E. Hazelton Ave, , Stockton Calif. <br /> . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued/017-77 <br /> Application is hereby made to the San (CompleteJ Joaquin Local Health District for a permit to <br /> an Joaquin" <br /> and/or install the-work ,herein described, This application is made in.. construct <br /> County Ordinance..No. 1862. and the Rules and Regulations of the San JoaquinpLocal eHealth SDistrict. P <br /> JOB ADDRESS/LOCATION ct. <br /> CENSUS TRACT r <br /> Owner's Name <br /> Phone r <br /> Address - # <br /> City - <br /> Contractor's Name _ <br /> *ieense a hone <br /> TYPE OF WORK (Check) : NEW WELL 1WDEEPEN --- <br /> RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ) SEWER LINES '7 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTICOTWEL <br /> INTENDED USE TYPE OF WELL I: <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing , <br /> __Gravel Pack Depth, of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Information <br /> Geophysical Other Other <br /> ..` �—•---- - -�� <br /> _ Surface Seal. Installed By: 4 <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump . " <br /> H.P. f <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR; State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all, laws and regulations of the San Joaquin Local Health District � <br />.nd the State of California pertaining to or regulating well -construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BLL DRILLERS REPORT of the well and notify them before putting . the. well in use.. The above � <br /> nformation is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A F NAL INSPECTION. <br /> IGNED <br /> TITLE_ <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> RASE I FOR 'DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY € <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION -` <br /> VSPECTION BY D E INSPECTION BY - - <br /> /`. DATE <br /> E H 1426 Rev- 1-74 '0 7 ?M <br />