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G SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (200) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Wiz. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <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,O dinance No. 1862 and the Rule and Regulations of the San Joaquin Local Health District, <br /> .B ADDRESS/LOCATION . -- <br /> CENSUS TRACT 02-7 <br /> Owner's, Name 929 a Phone <br /> Address <br /> City , ez <br /> Contractor's Nam <br /> l 6. License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ UMP REPAIR/? PUMP REPLACEMENT 17 <br /> Other / 7 <br /> DISTANCE TO NEAREST SEPTIC TANKS EWER LINES P <br /> SEWAGE DISPOSA FIELD IT PRIVY <br /> ,CESSPOOL/SEEPAGE PIT _ OTHER t <br /> PROPERTY LINE - <br /> INTENDPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL�� <br /> ED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool 'Dia. of Well Excavation <br /> Do�stiC/private Drilledr� <br /> Dia. of Well Casing 211 <br /> Domestic/public Driven Gauge'of -Casing <br /> ��Irr.igation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection •" Rotary Type of Grout <br /> Disposal Other ` Other Information <br /> Geophysical Surface Seal Installed BY: <br /> s <br />.PUMP INSTALLATION: ContractorM <br /> �r-�o.�r L, fir/Z <br /> Type of Pump <br /> �.. H.P.L11l� <br /> PUMP REPLACEMENT: State Work Done,-� f <br /> PUMP ,REPAIR: /7 .State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . <br /> a _A V Approximate Depth <br /> Describe Material, and Procedure ---- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind 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 /> 4ELL 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 />'RIOR TO GROUT G 'AN A F INS <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />?HASE I FOR DEPARTMENT USE ONLY <br /> OFT A ION ACCEPTED BY <br /> LDDITIONAL COMMENTS: DATE <br /> "ZILL 27 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />:NSPECTiON BY DATE -� INSPECTION. BY. /lid DATE / - • 7,:7 <br /> x <br /> - E-H- 1426. Reo_ 7-74 <br />