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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 an the ule nd Regulati of the San Joaquin Local Health District. <br /> JOB ADDRES5/LOGATTON -- ��• CENSUS TRACT <br /> OwnertsName Phone <br /> Address ` � City ' j <br /> Contractor's Name <br /> • .License # ' 'I Phone <br /> TYPE OF WORK (Check): NEW WELL /ff/ DEEPEN '/? j <br /> ALRECONDITION /-7 DESTRUCTION / <br /> PUMP INSTLATION PUMP REPAIR'/-7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK IM4 SEWER LINES PIT PRIVY <br /> SEWAGE DISRO AL FIELD .LQ" CESSPOOL/SEEPAGE PIT OTHER .� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation hf <br /> Z Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 4Q4z�0t. • <br /> Disposal Other Other Information 7VdA- <br /> Geophysical Surface Seal Installed B : <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H•P• <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work_.,eow000r <br /> e <br /> L <br /> ' DESTRUCTION OF WELL: : Well Diamet" er Ap roximate Depth <br /> Describe ial and P ocedure <br /> - - _ . . <br /> I reb agree t` o "co apt ra3t 1 - s�of the San oaqui Local HealthDistrict <br /> an -t-he-S�tafe oaf '5-1 lifornia 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 <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.af my.knowledge and belief. I WILL CALL ,FOR A GROUT INSPECTION <br /> iPRIOR TO GROUTING -AND INALPELT N. <br /> SIGNED TITLE <br /> + D PLO LAN ON REVERSE SIDE <br /> kFM DEPARTMENT USE ONLY <br /> 1 PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 117GROUT INSPECTION PHASE I F INSPECTIO <br /> INSPECTION B`77 DATE Z i5 INSPECTION E_1-- DATE <br /> h/75 2M <br />