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SAN JOAQUIN LOCAL HiATH DISTRICT <br /> FOR;OFFICE USE: 1b01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 =_397/-J <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued9 <br /> (Complete In Triplicate) <br /> Applicata 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 Regulatio of the San as uin .Local Health District. <br /> JOB ADDRESS/LOCATION S, �v ,CENSUS TRACT <br /> Owner's Name Phone . <br /> Address S 2 7 City . ,alof <br /> .Contractor's Name License hone <br /> , <br /> �; .. <br /> TYPE OF WORK (Check). -NEW WELL.. DEEPEN '/? 'RECONDITION f7 DESxRUCTION <br /> PUMP INSTALLATION ' REPAIR ' PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L�NES PIT PRIVY <br /> SEWAGE DISPOS SD <br /> FIELD ?0-CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X _ Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing y <br /> Irrigation Gravel Pack Depth of Grout Seal 4-0 <br /> Cathodic Protection Rotary Type of Grout 9 __ <br /> Disposal Other Other Information . <br /> Geophysical Su ace Seal Installed 'B : <br /> .PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ` <br /> :PUMP REPLACEMENT: / { State Work Done , <br /> ?UMF .REPAIR: / / State Work Done <br /> DES=TRUCTION OF WELL: Well Diameter.T - Approximate Depth 'C-20- 0 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well"construction.. Within FIFTEEN DAYS T,%\, <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric� <br />' WELL DRILLERS REPORT of the well and notify them before putting. the.:well. in.use.. , .The above <br /> information is ue to the-beUPFEliTTON.my..knowledge and belief. I WILL FOR A -GROUT .INSPECTION <br /> i PRIOR TO GROUTI D NAL - <br /> .SIGNED TITLE <br />{ D LOT PLAN ON REVERSE SIDWE*A <br /> I V ILOR DEPARTMENT USE ONLY <br /> PHASE I �' <br /> APPLICATION ACCEPTED BY DATE ' 1 r <br /> 'ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE II FINAL 'INSPECTION <br /> ' INSPECTION BY DATE 1S- J i INSPECTION BY DATE <br /> k C&� <br />