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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFI` CE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> In( e 77 <br /> Application is hereby made to the SanJoaquzn Local Triplicate) <br /> District for a permit toconstruct <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l � r <br /> ro /ion CENSUS TRACT <br /> Owner's Name � } c-- 1) � <br /> Address e, � E <br /> Phone S�y- Q <br /> k 4 <br /> CityIS <br /> / <br /> Contractor's Name • h <br /> License,, Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN/_% RECONDITION / / DESTRUCTION <br /> r PUMP INSTALLATION / / PUMP REPAIR / /—PUMP , <br /> Other REPLACEMENT <br /> 1 / J <br /> .... <br /> b r <br />( DISTANCE TO NEAREST: SEPTIC'TANK <br /> -SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE(_PTT <br /> PROPERTY LINE -- P OTHER <br /> PRIVATE DOMESTIC INTENDED USE C WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS Domestic/private Cable Tool Dia, of Well Excavation <br /> �' <br /> Domestic Dia. of Well Casing <br /> /public Drilled Driven Gauge of Casing-"--: <br /> Irrigation Gravel Pack - <br />�^ Cathodic Protection RotaryDepth of Grout Seal � '� <br /> Disposal Type of Grout i <br /> OtherOther Information <br /> Geophysical Surface Seal Installed B : <br /> i <br /> PUMP INSTALLATION: t <br /> Contractor r � <br /> -Type of Pump <br /> s , . H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> r . t <br /> PUMP .REPAIR: ' � State. Work Done � <br /> DESTRUCTION OF"WELL. Well,-Diardeter i � <br /> F <br /> :Describe Material-and Procedure Approximate Depth <br /> ----�. <br /> I hereby agree to `comply with all laws .and regulations of the an 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 -furn shrthe­ San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of tfie well and- notify them.before�putting `the well. in use. The above <br /> information is true to the bke'st° of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G TING AND A F AL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I FOR DEPARTMENT USE <br /> LPPLICATION ACCEPTED BY <br /> J)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION , <br />:NSPECTION BY PHASE II /FI-NAL, INSPECTION <br /> DATE INSPECTION BY DATE a? 7 ,j? <br /> M F <br /> E H 1426 Rev. 1-74 1/77 9m <br /> l <br />