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f�) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1 .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T <br /> HIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r-1 ,72 <br /> Gp -t-r v � (Complete In Triplicate} � 2GS- <br /> .1 . <br /> Application 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> �� © L CENSUS TRACT <br /> 10rBYDRESS.//LOCA ON r _ <br /> spa Phone ES—9- Z <br /> Owner's Name <br /> City <br /> Address <br /> t <br /> Contractor's Name <br /> _} Lice se (� 9 1�'�'Phonerf ycS�3� <br /> TYPE OF WORK (Check) : NEW WELL /�GY llEEPEN / RECON➢ITION I� DESTRUCTION /�T <br /> i PUMP INSTALLATION/�UME REPAIR/ / PUMP REPLACEMENT /� <br /> /% , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES PIT PRIVY <br /> SEWAGE DI7.SPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY' LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �_/cyCable Tool Dia. of Well Excavation " -�; <br /> Drilled Dia. of Well Casing " '~ <br /> Domestic/private �-j -T-�� <br /> Domestic/public Driven Gauge of Casing 3 <br /> ��Irrigation' ; Gravel Pack Depth of Grout Seal �\ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ace Seal Installed B / - <br /> a PUMP INSTALLATION: Contractor <br /> H.P. I <br /> Type of�Fump <br /> PUMP REPLACEMENT: / / State; Work Done <br /> Imo•/ <br /> St-a.te_Wor-k-�Done - T <br /> DES'•TRUCTION-OF WELL:- -We1:1�Diamet`r _ - ._ _ Approximate Depth <br /> Describe Material,,and Procedure <br /> I hereby agree to comply with all lavas and regulations of the San Joaquin Local Health District <br /> ,fnd the State of California pertainin.grto 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 /> TELL DRILLERS REPORT of the well and ziotify them before putting the well in use.' The above <br /> Information is true to the best of _Ti-knowledge and belief. I WILL CALL-FOR A GROUT INSPECTION <br /> r PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ;FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> - 7' -PHASE--III/FINAL=INSPECTION '�---�•- <br /> PHASE II GROUT INSPECTION_' - DATE 7 <br /> Is INSPECTION BY DATE INSPECTION BY <br />