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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.-_, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7X-7#7&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L2-L&- <br /> (Complete In Triplicate) <br /> Application is hereby made to the Stan 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 /> Courtly Ordinance No. 1862 and the Res nd g a tiolLis of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 9 <br /> Owner's Name Phone , <br /> Address City <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION / .7 DESTRUCTION /7T,. - <br /> PUMP INSTALLATION / / FUME REPAIR`/7 PUMP REPLACEMENT <br /> -Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT ,PRIVY <br /> SEWAGE DISPOsA7F_IELD 73.E CESSP00L/SEEPAGE PIT OTHER <br /> PROPERTY DINE -- 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 o — <br /> t <br /> Domestic/public Driven Gauge of Casing <br /> irrigation <br /> Gravel Pack Depth of Grout Seal S-9 . , <br /> Cathodic Protection Rotary Type q£ Grout �o .. <br /> Disposal Other Other Information ' ' <br /> E Geophysical Surface Seal. I stalled 'B <br /> rPUMP INSTALLATION-. Contractor _ ��- ... <br /> Type of Pump— H.P H.P. <br /> • z <br /> PUMP REPLACEMENT: . / State Work Done -- . - <br /> PUMP .REPAIR: State Work Done - y <br /> ` DESTRUCTION OF WELL: Well Diameter =- ` """ " ,Approximate Depth <br /> Describe Material and Procedure <br /> lI hereby agree to comply with all laws and leg 1atibns`"of'• the San Joaquin Local Health- District <br /> and the State of California pertaining to or regulating weli'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 FINAL INSPECTION. , <br /> jSIGNED TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1s FOR DEPARTMENT USE ONLY <br /> PHASE I y <br /> APPLICATION' ACCEPTEDFBY DATE /O / - <br /> ADDITIONAL'COMMENTS: <br /> pHA O. INSPECTION P AIMNAL INSPECTI <br /> INSPECTION BY DATE INSPECTION B DATE <br /> V7s 2M <br />