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4 <br /> SAN JOAQUIN LOQrL HEALTH DISTRICT <br /> FOE OFFI�CE USE: 160 . E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made to the San (Joaquin eLo alIn rHealthtDistrict for a permit <br /> and/or install the work herein described. This application is made in compliancetwithnSanu <br /> ct <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Jo <br /> Local Health Districtn <br /> JOB ADDRESS/LOCATION SC1/ � �� , <br /> CENSUS TRACT <br /> Owner's Name �/ <br /> II L Phone J- (J�Y <br /> Address 32 a � U 6�Ja r� U , <br /> Contractor' City <br /> s Name <br /> E' License # Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> /7 DEEPEN/ / RECONDITION /__7 DESTRUCTION /7 <br /> PUMP INSTALLATION ) PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE 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 <br /> TYPE OF WELL <br /> IndustriaCONSTRUCTION SPECIFICATIONS <br /> l Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 1 <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done (� <br /> PUMP ,.REPAIR: <br /> State Work Done <br />)ESTRUCTTON OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO R UTING D AL I E CTION. <br /> IGNED <br /> TITLE if <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> RASE I <br /> FOR DEPARTMENT USE ONLY <br /> ` - <br /> PPLICATION ACCEPTED L <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GRO /.Z7_Z_ <br /> UT INSPECTION PHASE TTI/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 9M <br />