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S SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOF OFFICt USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,717 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE TSSUED . Date Issued/�-/ 7 <br /> - .- - <br /> � (Complete In Triplicate) <br /> 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 Or roan Na 862 nd the Rules a ,Rego at' "n f Sa Joaquin Local. Health. District. <br /> ` <br /> JOB KESS/LO T 0 t? Ste, �.fd�rD2 CENSUS .TRACT <br /> Owner's Name Phone <br /> Address City <br /> � C <br /> .Contractor s Name {� ��� �j - -_Licenseti. Phone' -� <br /> ..- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 TYPE OF WELL 1�_ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ;, "i ia. of Well Excavation �#% ' <br /> Domestic/private _ Drilled' " " Dia.. of Well- Casing <br /> Domestic/public Driven Gauge of Casing 4 <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection _ Rotary .Z Type of Grout - -. <br /> Disposal Other "W Other Information Ap j5jg�-_)_ <br />[ - Geophysical Surface Seal Installed 1i `n <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: / t/ State Work Done ` <br /> PUMP .REPAIR: /_ / State Work -Done - <br />� DES•TRUCTION OF WELL: Well Diameter lqf 4 Approximate Depth l2LL <br /> Describe Material- a Procedure S �5 <br /> I, PNS u : r,10 Ag AJ <br /> I hereby agree to comply with all laws and re uladio s of the San Joaquin Local Health District <br /> and the State of California --pertaining td 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 thewell in use.. The above <br /> information is true to the best f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUT;4G ANA A AL I] ECTION. �- <br /> t SIGNED TITLE <br /> (DRAW PLOT-'PLAN-ON REVERSE SID ft <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY µ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE M I�TION BY DATJE <br /> �� 2M <br />