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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 7 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-1-7G <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 mad6 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 t CENSUS TRACT ' <br /> M <br /> Owner's Name f 1 A d'�'s Phone ' <br /> Address �, a r City . <br /> Contractor's Name License # Phone -74 <br /> TYPE OF WORK (Check): NEW WELL/7DEEPEN -/-`T RECONDITION /7 DESTRUCTION !-T <br /> PUMP INSTALLATION/ / PUMP REPAIR �g PUMP REPLACEMENT T7 <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br />'R Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Dane _. :A� �' ,f/J� -A <br /> DESTRUCTION OF WELL: . Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply with all laws and regulations of the San 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 furnish the San Joaquin Local Health District a <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.knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> [PRIOR TO 5RUTJNG 'AND A FINAL INSPECT N. <br /> SIGNED TITLE r'aA <br /> To 7 (DRAW TM11 OFT-P-M-ON REV SE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Tt"II 7/.9G n.� -7t ),/7ri 2M <br />