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► JOAQUIN LOCAL HEALTH DISTRICT" <br /> FO - OFFICE USE: 16G--,,.E. Hazelton Ave. Stockton, Ca,---.:. <br /> Telephone : (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;?Zz <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) F [Llt co <br /> pplicatio is hereby made to the San Joaquin Local Health District for Efruct <br /> ad/or install the work herein described. This application is made in compliance with- San Joaquit <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health. District, <br /> 3B ADDRESS/LOCATION 3 , <br /> CENSUS TRACT <br /> aner's Name P�hhne <br /> � � <br /> 1dress <br /> �s City <br /> 3ntractor's Name License PhoneIL <br /> l <br /> iPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION /- <br /> AL _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMF REPLACEMENT <br /> Other / / 7` <br /> ISTANCE TO NEAREST: SEPTIC TANK _Z_�b1 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1.2 0-' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing N, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation L <br /> g Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: V State Work Done <br /> UMP .REPAIR: / / State Work Done <br /> i <br /> ES-TRUCTION OF WELL: Well Diameter �1 <br /> —� Approximate Depth 1 Q p <br /> Describe Material and Procedure <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 /> FELL DRILLERS REPORT of the weland notify them before putting the well in use. The above <br /> nformation is tr e to the be t a my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> RIOR TO GROUTIN 'AND A FIN CTION. n r <br /> IGNED y "G TITLE y <br /> I <br /> DRAW PLOT PLAN ON REVERSE SID <br /> 'RASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> _NSPECTION BY DATE INSPECTION BY DATE /;' 7r <br /> E H 1426 Rev. - I-74 b/77 _ 2M <br />