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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR­OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)7466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-311 <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued;�--� f <br /> ;A (Complete In Triplicate) <br /> k 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 and the Rules and Regulationsf of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name _ <br /> Address Cit <br /> y -'sem <br /> Contractor's Name_ <br /> ease #��6d, __Phone__ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION — <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT4 <br /> Other / / „ <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> W SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ OTHER <br /> k PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE (TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial fi Cable Tool Dia, of Well Excavation <br /> Domestic/private " Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation F Gravel Pack. Depth of Grout. Seal <br /> Cathodic Protection- f Rotary Type of Grout 1 <br /> I Disposal 'y Other Other Information; <br /> Geophysical Surface Seal Installed By: <br /> ' <br /> ' PUMP INSTALLATION: Contractor' <br /> Type of Pump H.Z. 7 <br /> PUMP REPLACEMENT: '-/ %r.Sta-te Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> i DESTRUCTION 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 DAIS <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 abo'v'e <br /> information is true to the best of my knowledge and belief. I WILL CALLtFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AUD FINAL INSPEC ION. <br /> i SIGNED TITLE -� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ! ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION" <br /> � <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE �7-7 <br /> 1f77 _ 2M <br /> R 14 142A RPV. 1-74 - ._ <br />