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r _ <br /> SAN JOAQUIN 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. 11F' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-1-3- <br /> (Complete <br /> /3-(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. .18622 an' <br /> the and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. CENSUS TRACT <br /> 77 <br /> f Owner's NameWPhone e <br /> Address city <br /> � / r <br /> Contractor's Name Licens� �3/J Phorr�-�`��5 >r <br /> { <br /> i <br /> f-.-TY:RE-OF-WORK(Check.)-;� NEW-WELL�=I /--DEEPEN f / _RECONI}ITION /__. DESTRUCTION � <br /> / <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT /_7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER •LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private f Drilled Dia. of Well Casing <br /> Domestic/public given -'Gauge of Casing <br /> Irrigation . , Gravel Pack "� -Depth of Grout Seal <br /> Cathodic Protection Rotary Type` of Grout C <br /> Disposal ➢ Other Other Information <br /> Geophysical Surface_ Seal Installed By: (� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: — <br /> / ' `State Work" Don -- <br /> DESTRUCTION OF WELL: Well Diameter App ximate 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 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 GROUTING AND A FINAI; INSPECTION. <br /> SIGNED tTITLE <br /> ► DRAW:PL'T PLAN "ON REVERSE SIDE) = � " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE I I/F NAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY ATE 26V7 <br /> 5. 3 76 2M <br /> E H 1426 Rev. 1=74 � � � _. <br />