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Gr7� �u S JOAQUIN LOCAL HEALTH DISTRICT <br /> OL OFFICE USE: (60 .. Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �7�ja <br /> k!. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Id/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> FB ADDRESS/LOCATION $, p CENSUS TRACT <br /> rer's Name It Phone <br /> 1dress l 72 c ft City <br /> ntractor's NameC_ �_, - License # r <br /> PE OF WORK (Check): NEW WELL/ / DEEPEN '/—/ RECONDITION / / DESTRUCTION /? <br /> 4 " PUMP INSTALLATION I I PUMP REPAIR PUMP REPLACEMENT /-J <br /> Other <br /> LSTANCE 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 /> { _ Domestic/public. Driven Gauge of Casing �} <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> e <br /> PUMP REPLACEMENT:..-_. / / State Work Done <br /> [)MP REPAIR: / !/ State Work Done A <br /> ,S.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> hd 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Nreformation is true to- the-best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TO G T NG ANDA FINAL I IO � j � <br /> SIGNEDA,I T I T L E <br /> W. L T PLAN ON UVERSE SIDE) it <br /> IP FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION I <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev, 1-74 C/3 3/76 2M <br />