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SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FOAZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif._ <br /> Telephone: (209) :466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S X95 , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f� (Complete In Triplicate) .A .F ' <br /> Application is hereby made to the San Joaquin LocallRealth 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 ules and uiat o s of �e�San Joaquin Local Health Diat�rict. � <br /> *� . <br /> JOE-,ADDRESS/LOCATION If�_ T w � CENSUS TRACT' - <br /> Owner's Name Phone 7z �� <br /> ;Address /� el 9 y City <br /> cense `"' hone <br /> Contractors Name <br /> TYPE OF WORK (Check} : NEW WELL/��DEEPEN RECONDITiON /—J DESTRUCTION I=T <br /> PUMP INSTALLATION /14--7LMP REPAIR / I PUMP REPLACEMENT /7 <br /> Other / / <br /> �] <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 itTYPE OF WELL CONSTRUCTION SPECIFICATIONS 1/ <br /> Industrial I able Tool Dia. of Well Excavation <br /> Zrpomestic/private + Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack ;Depth of Grout Seal S <br /> Cathodic Protection Rotary !Type of Grout <br /> Disposal E Other Other .Information <br /> Geophysical Surface Seal Installed BY: <br /> i <br /> PUMP INSTALLATION: F�. <br /> Contractor <br /> Type of Pump •P• <br /> PUMP REPLACEMENT: / / ; State Work Done <br /> PUMP iREPAIR: / / State Work Done <br /> ,PES TRUCTION OF_WELL: Well Diameter _ Approximate Depth <br /> x 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 a <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 GROU D A FINA& IMPECTION. J. - <br /> t' �' <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I I • <br /> APPLICATION ACCEPTED BY DATE ��- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION r PHASE IIT FINAL INSPECTION <br /> BY , , t DATE INSPECTION BY DATE <br /> \INSPECTION <br /> =: i. { <br /> w4 - 1-74 2M F <br /> ,. H 1426 Rev. 1-74 <br />