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SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 �Q3/9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�` <br /> THISI'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 1�� lDistrict <br /> ct <br /> aionisinrcomplianceermit twith Sanu <br /> Application is hereby made to'the San JoacLuin LocalJoaquin � <br /> and/or install the work herein described. PP <br /> !the Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1$62 and, � <br /> .. GENSUS TRACT ! <br /> JOB ADDRESS/LOCATION <br /> i Phone - 7 3 <br /> Owner's Name 1 <br /> c� O City S UG <br /> Address 3 J Y <br /> Contractor' s Name <br /> License Phone <br /> !t <br /> TYPE OF WORK (Check) : NEW WELL f / DEEPEN/ / RECONDITION I PUMPESTRUCTION REPLACEMENT_717 <br /> PUMP INSTALLATION /;71 PUMP REPAIR ./ / <br /> Other'/ / <br /> ` ! PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LINE PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS C� <br /> INTENDED USE TYPE OF WELL <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> t Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Irrigation ! Gravel Pack De P <br /> Type of Grout <br /> Cathodic Protection 1 Rotary Other Information <br /> Disposal l! Other <br /> Surface Seal Installed <br /> Geophysical B <br /> f ' I S:s <br /> JPUMP INSTALLATION. Contractor H.P. S <br /> Type of Pump 45 <br /> PUMP REPLACEMENT S <br /> : I / , <br /> tate Work Done b' <br /> + PUMP .REPAIR: / / State Work Done <br /> I Approximate Depth _ <br /> DESTRUCTION OF WELL: We 11 ;Diameter <br /> Describe Material and Procedure <br /> 1y with all laws and regulations of the San Joaquin Local <br /> � I hereby agree to comply Health District <br /> in FIFTEEN <br /> and the State of California pertaining to of regulatiwill ngshethec nstruction.Local Health Distan Dict a <br /> � aftex completion of my work on a new well, <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 GROUTIW AND A FINAL INSPECTION. TITLE <br /> SIGNED { PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> r,PHASE I <br /> ` DATE <br /> APPLICATION ACCEPTED BY f <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II G T NS CTIONINSPECTION BY DATE <br /> INSPECTION BY DA E 067-f ez-Vf <br /> r y cM <br />