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OFFICE USE:FOEV JOAQUIN LOCAL HEALTH DISTRICT, <br /> � 160( ,i. Hazelton ,Ave. , Stockton, Cal_ <br /> Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,s Sd_u) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED.. Date Issued <br /> i <br /> �! IR (complete In. Triplicate) <br /> Applicati.on is hereby 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 compliance with San Joaqu`1 <br /> County Ordinance- No. 1862 and-the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION <br /> f y CENSUS TRACT <br /> Owners Name lienPhone <br /> Address <br /> City <br /> Contractor's Name License l Phone ' <br /> TYPE OF WORK (Check): NEW WELL ./V'DEEPEN •/?` RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ PUMP REPLACEMENT /7 <br /> Other / 7 . <br /> I <br />( .DISTANCE TO NEAREST: SEPTIC TANK_5 Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAT FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELT.' PUBLIC DOMESTIC WELL <br /> [INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> !industrial 4 Cable Tool Dia. of Well Excavation <br /> „r Domestic/{private L_/Drilled Dia. of Well Casing i s. <br /> rbomestic/pub;lic E Driven Cr <br /> Gauge of Casing <br /> :Irrigation p� Gravel Pack Depth of Grout Seal <br /> Cathodic Protechon Rotary f Grout <br /> _ Disposal Other ,6°�,✓T�n/i�- <br /> ' .� ei Information , <br /> Geophysical Surface Seal Installed By: g <br /> PUMP INSTALLATION: Contractor <br /> #. . Type of Pump . H.P. <br /> PUMP REPLACEMENT: State Work Done. <br /> PUMP REPAIR: /E / :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . <br /> Approximate Depth <br /> Describe Material and Procedure <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 well "construction. 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 /> information is 'true 'td the .beat of- my.knowledge and belief. I WILL. CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GR UTING`AN AL -INS P CTIO <br /> S IGNED�I 9 <br /> TITLE I <br /> (DRAW 7OT—PLAN ON REVERSE SIDE <br /> 0 D ARTMENT USE ONLY <br /> PHASE I � . q . <br /> APPLICATION ACCEPTED BY DATE (J ` j~� <br /> ADDITIONAL COMMENTS: r <br /> i PHASE II GROUT INSPECTION PHASE III IAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> EH �1426 Rev. 1=74 II ®` t./7C o <br /> �� <br />