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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFFICE USE: ��160l E. Hazelton Ave. , Stockton, Calif. <br /> �" <br /> Telephone: &*`46-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T -1-S S <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issues 5=i 7-75 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health DiAtrice for a permit to ,construct <br /> and/or install the work herein described. This application is made in compliance with San Joaq% <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Districl <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phonei4l -.. <br /> e/ <br /> Address a City <br /> r License 0 Phone ° <br /> Contractor s Name <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/_� RECONDITION /� DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7PUMP REPLACEMENT f7, <br /> Other /-7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ! <br /> mestic/ ublic:' Driven Gauge of Casing <br /> i rri alio Gravel Pack y''Depth of Grout Seal <br /> Cat odic Protection Rotary " Type of Grout <br /> Disposal Other Other Information <br /> w- Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. a,5— <br /> PUMP <br /> REPLACEMENT: /% State'Work Done <br /> PUMPtREPAIR: ,- Ll State Work Done , <br /> VEST.RUCTION 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 <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 GROUTOG AN A FINAL I PECTION. <br /> SIGNED PLAN ON TITLE <br /> (DRAW PLOT REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �i 11^�'r -- — /� DATE . J <br /> I ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - <br /> :DATE /S1117d <br /> FR' <br />