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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' gGFOEFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. l <br /> Telephone: (209) 466-6781 Permit No. % <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ute'/��70 <br /> (Complete In Triplicate) <br /> st <br /> Application is hereby made to the San Joaquin Locct <br /> is <br /> Distmade inrict rco pliancea permit twithnSanuJoaquin <br /> and/or install. the work herein described. This pp <br /> County Ordinance No. .l$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> {SS LOCATION U- CENSUS TRACT <br /> JOB ADDRE / �� �- -- <br /> Phone <br /> Owner's Name eff A <br /> city <br />! Address = <br /> License ,Phone <br /> Contractor's Name 4;1zi �oµ•� "� � <br /> i <br /> TYPE OF WORK (Check) : NEW WELLb4 DEEPEN "/ / RECONDITION / / DESTRUCTION <br /> PUMP ITA <br /> _NS _i..LATION /�/I PUMP REPAIR / /— PUMP .REPLACEMENT—�../._ � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��a _ SEWER LINES `ao PIT PRIVY—1 \Qt <br /> SEWAGE DISPOSAL FIELD 12a CESSPOOL/SEEPAGE PIC DOMESTIC OTHER <br /> PROPERTY LINE X PRIVATE DOMESTIC WELLCONSTRUCTION SPECIFICATIONS <br /> 4 INTENDED USE TYPE OF WELL <br /> � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .. Domestic/private - Drilled Dia, of Well Casing <br /> Driven Gauge of Casing <br /> Domestic/Public <br /> [[[ Irrigation ,., -- Gravel Pack Depth of Grout Seal Sal f <br /> Cathodic Protection _�^ Rotary Type of Grout � !„ C <br /> Disposal Other - _ Other Information <br /> Geophysical -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor • _ Y H.P. <br /> Type of PumpG <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> `kr <br /> j€k PUMP .REPAIR: / / State Work Done46 <br /> +; <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> h <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 �Cala.fornla pertaining1.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'DistrictJz <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 GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SID ) <br /> Li FOR DEPARTMENT USE ONLY <br /> r PHASE I DATE Z <br /> APPLICATION ACCEPTED <br /> 4 <br /> ADDITIONAL COMMENTS: PHASE I I/FINAL INSPECTION <br /> PHASE II ROUT INSPECTION DATE <br /> t INSPECTION BY HATE - Qj INSPECTION BY — <br /> / 077 2M z <br />