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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE DFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7-L-_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7�3o�7d <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> is made in compliance with San Joaquin <br /> and/or install the work herein described. This application <br /> County -Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone _ <br /> Owner's Name <br /> r� <br /> Address <br /> City <br /> 's Name License To Phone J� <br /> Contractor ] <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN I / RECONDITION_/ / = DESTRUCTION /_'T <br /> PUMP INSTALLATION "/ / PUMP REPAIR / PUMP REPLACEMENT I <br /> I <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 PUBLIC DOMESTIC WELL <br /> INTENDED 'USE-USETYPE'OF WELL - - ---`" CONSTRUCTION SPECIFICATIONS \ <br /> �;.. . r <br /> 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 <br /> _Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of -Pump <br /> PUMP REPLACEMENT: / State Work Done/ � <br /> PUMP .REPAIR: /�/ State Work Done <br /> Approximate-Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> y <br /> Describe Material and Procedure - <br /> I hereby agree to comply with all laws and..regula'tions�of ,the�San'Joaquin Local Health District <br /> and the State of California pertaining"to or-regulating-`raell construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; I�wilI furnish the:=San Joaquin Local Health District a <br /> WELL DRILLERS--REPORT of the wel-l-a6d notify them before putting the well 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 UTING FIN. I F ION. TITLE <br /> SIGNED :. 1. <br /> p PLOT PLAN ON REV RSE SIDE <br /> DEP MENT USE ONLY <br /> PHASE I DATE ,/7 Z <br /> APPLICATION ACCEPTED Y <br /> ADDITIONAL COMMENTS: P SE IN INSPECTI <br /> ` PHASE 11 GROUT INSPECTION INSPECTION DATE <br /> INSPECTION BY DATE <br /> 376 2M <br /> E H 1426 Rev. 1-74 �ti. <br />