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AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /160SIE. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��� <br /> �j THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //-a <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District four a permit to construct <br /> andf/or install. the work herein described. This application is made in compliance with San Joaquin <br /> -County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owrier's Name ' . .� Phone , <br /> Address �<>'"� City <br /> Co tractor'a Name T , License Phone E~ <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 <br /> hDESTRUCTION] <br /> PUMP INSTALLATION "/— M �P / ,PUMP,REPLACE <br /> T /7 <br /> Other +/—/ <br /> DISTANCE TO NEAREST: SEPTIC "TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT, OTHER <br /> PROPERTY, LINE - PRIVATE DOMESTIC-WELL'-'` ` ' PUBLrC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL s CONSTRUCTION SPECIFICATIONS L� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> f Domestic/private 1 $ Drilled Dia. of Well .Casing <br /> dh Domestic/public 1 € Driven 1 Gauge of Casing 1. <br /> if, irrigation ! s Gravel Pack Depth of Grout Seal: <br /> Cathodic Protection i Rotary Type of Grout _,; <br /> 'il' ' Disposal i Other Other Informatian € <br /> J11 'Geophysical r..,..�_., . ,,.. �.. <br /> - Surface Seal Installed Big:.. <br /> PUMP INSTALLATION: Contractor ; k <br /> i <br /> Type of Pump r H.P. <br /> PUNY REPLACEMENT: . / IT State Work Done g <br /> PUMPFtEPATR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameterf <br /> Approximate Depth <br /> Describe:Material a d Procedure ri <br /> I hereby agree to comply wither 1 laws and regu ations of the San Joaquin Local- Health District <br /> and Ithe State of California periaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work oix'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..wel1. in.use.... -The above <br /> information is true to the-best ;of- my..knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO GROU NG AND A F1 'IIN PECTION. <br /> SIGNED } <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE),- <br /> FOR <br /> IDE FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE �/;� 7g <br /> ADDITIONAL COMMENTS: I <br /> 4� PHASE III I ECT"N PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE ' - -- _INSPECTION INSPECTION B_Y In M DATE ;` 7 <br /> E H 1.426Rev. 1-74 r h/79M <br />