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T e� <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> ' Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1.7d <br /> (Complete In Triplicate) <br /> Application 1,s A'ereby 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 incompliance_with San Joaquin <br /> County Ordinaii�e Ido: 4862 zad the Rules and Regulations of the San Joaquin Local Health District. <br /> q <br /> J& ADDRESS/LOCATION ! CENSUS TRACT <br /> Owner's Name `7'J? Phone <br /> Address / s �7+' '� City <br /> Contractor's Name 1!!�✓ �T - License A�Vdev Phone <br /> TY'E OF WORK (check) :` NEW WELL / / DEEP <br /> E /% RECONDITION /- DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT O <br /> Other / / W <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' 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 By:-&& <br /> PUMP INSTALLATION: 'Contractor4/e�g <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT`: / / State WorkDone <br /> PUMP '.REPAIR: / / State Work Done <br /> PES-TRUCTION OF WELL: Well Diameter Q'� �,.x 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 REPORTofthe well and notify them before putting the .well in use. The above <br /> information pis true to the best of my, knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION, ACCEPTED BY DATE <br /> 7. <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT-IN ECTION PHAS III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE <br /> 1 I7 _ 2M <br /> E H 1426 Re' v'-' 4 14 <br />