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SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: • (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--331 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-11-7S <br /> (Complete In Triplicate) <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 Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION 7L Izd CENSUS TRACT 07 - ros+o Zq <br /> Owner's Name .A Phone ' Z� <br /> Address 'i <br /> Contractor Name �(��/� License ' Phone <br /> TYPE OF WORK (Check): NEW'WELL '/-7 DEEPEN /7 RECONDITI N /-7, DESTRUCTION f7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR ,2K . . . . . . . <br /> PUMP REPLACEMENT /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" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabl Tool Dia. of Well Excavation 4 <br /> Domestic/private Dri -Tool <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <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 /> Type of Pump H.P. <br /> _ I <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMPIREPAIR: <br /> / State Work Done <br /> T1 i <br /> I <br /> IIE&TgUCTION OF WELL: Well Diameter Approximate Depth i <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 I <br /> after completion of my work on 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 .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 G TING ANVA. FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO PARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED B C DATE. <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE S <br /> E H 1426 Rev. J-774 f h/75 2M <br />