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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi OFFICE USE: -7 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> rAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM D , <br /> ATE ISSUED Date •Issued L-aR <br /> Application is hereby made to the San (Joaquin LocalrHealthtDistrict for <br /> a permit ,to construct <br /> and/oz install the wozk .herein described. This application is made in compliance with San Joa uin_ <br /> County Ordinance -No.. 1862 and the Rules and Regulations of the San Joaquin.Local Health District. <br /> JOB ADDRESS/LOCATION." <br /> u 7'(-)./V <br /> Owner' CENSUS TRACT = <br /> s Name ,�;,�L $� � -.- <br /> { Phone <br /> Addres �1�^' <br /> s /f <br /> City <br /> Contractor's Name i. <br /> O� License #07� Phone v <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN /_/ RECONDITION / / DESTRUCTION /-7PUMP <br /> _ <br /> Ot rINSTALLATION /, / PUMP REPAIR �/ PUMP REPLACEMENT /'7 <br /> DISTANCE TO NEAREST: SEPTIC. TANK <br /> SEWER LINES PIT PRIVY <br /> v SEWAGE'1]IS-POSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMEST <br /> INTENDED USE TYPE OF WELL IC WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia:.40f Well Excavation 4 <br /> �T Domestic/private � Drilledi <br /> Domestic/public Dia. of Well Casing <br /> Driven Gauge of Casing r <br /> Irrigation Gravel Pack <br /> Depth of Grout Seal # <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal I Other Other Information <br /> _Geophysical ---- <br /> Surface- Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> , � <br /> Type of Pump - H.P. � <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: / / .State Work Done _ ..� <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure `- Approximate Depth <br /> % <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 onia new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL DRILLERS REPORT, of the well and notify them before putting. the. well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. I WILL CALL FO A GROUT INSPECTION <br />'RIOR TO GROU NG AND FINAL INSPECTION. <br /> i IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br />,RASE I FOR-DEPARTMENT USE ONLY <br />.PPLICATION ACCEPTED BY A .Y#1 `w i, • rr <br />-DDITIONAL COMMENTS: ' DATE <br /> PHASE II GROUT ..INSPECTION,, V <br /> NSPECTION BYPHASE IN r INSPECTION <br /> I)ATE 'INSPECTION BY DATE ^� <br /> E H 1426 Rev- 1-74 5.h '`1 ` r`,'� t <br />