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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF O FICE USE: 1601 H3zIton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. )7lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2:;77 <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 /> yjOrdi an No. 1862 and the Rules and Regulations of the San Joaquin Local Health. District. <br /> B ADDRESS/LOCATION ► V r Ve,ATRACT <br /> Owner's Name Phone <br /> rLI <br /> Address City <br /> r UA <br /> fit <br /> Contractor's Name Q License # hone <br /> f <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> j PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 t <br /> Other / / — <br /> - <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 Q' i <br /> INTENDED USE TYPE- OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> l Domestic/private 9 Drilled Dia, of Well CasingId <br /> °r <br /> Dome.s.ti.c/,p.ub.lic,,.:_- �.� y.. _ a Driven._--- _- -Gau � <br /> ge o€_Casing� <br /> { _ Irrigation Gravel Pack Depth of Grout Seal f <br />_ Cathodic Protection Rotary Type of Grout i <br /> .Disposal Other Other Information <br /> r <br /> Geophysical Surface Seal Installed B : j <br /> f <br /> PUMP INSTALLATION: Contractor .Z <br /> Type of Pump l-` H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />� DES•TRUCTION OF WELL: Well Diameter 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 j <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 L FOR A UT IN CTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> F04 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �Z,/ Z��. ,___ DATE 7 a <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHA III/ NAL INSPECTI N <br /> INSPICTION BY DATE INSPECTION BY DATE PZ <br /> 7 ._ . WeIC A)d 74"' . 6/77 . 2m. <br /> _.E`�i--1426 Rev- 1-74-,. <br />