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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 F. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '�7 <br /> (Complete In Triplicate) <br /> rebs made to the San Joaquin Local Health District for a permit to construct <br /> work herein described. This application is made in compliance with San Joaquin <br /> No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> :ION � CENSUS TRACT <br /> Phone <br /> C c R' ,, C- Q� City <br /> Name � <br /> f S o.1TL' �'a.�t►e a License / Phone <br /> (Check): NEW WELL L7 DEEPEN Q RECONDIT13N /-j DESTRUCTION L7 , <br /> PUMP INSTALLATION / PUMP REPAIR 1_7 PUMP REPLACEMENT <br /> Other <br /> TrAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DO*ffSTIC WELL PUBLIC DOMESTIC WELL <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Tial Cable Tool Dia, of Well Excavation <br /> -tic/private Drilled Dia. of Well Casing <br /> Lit/public Driven Gauge of Casing <br /> : .ration Gravel Pack Depth of Grout Seal <br />±hodic Protection Rotary Type of Grout <br />�;posal Other Other Information <br /> ophysical Surface Seal Installed BY: �± <br /> TALLATION: Contractor <br /> Type of Pump if H.P. <br /> LACEMENT: / / State Work Dore <br /> AIR: /% State Work Done <br /> ION Or WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Stage of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> npletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i -fERS REPORT of the well and notify them before putting the well in use. The above <br />'01 is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> AND A FINAL INSPECTION. <br /> TITLE o <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY n <br /> < <'F:I'TFD BY �C�/>�- DATE <br /> ,►: I I CR `'INSPECTION PHAS I/FOAL 4NSPECTIO / <br /> DATE 7 <br /> DATE: INSPECTION BY ��'�/'�` <br /> 1/77 2K <br />