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F _ JOAQUIN LOCAL HEALTH DISTRICT <br /> )E OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_ <br /> ' 77-1,A <br /> 77-�7t <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> { (Complete In Triplicate) <br /> lication is hereby made to the San Joaquin Local Iiealth District for a permit to construct <br /> /or install the work herein described. This application is made in compliance with San Joaqu <br /> �nty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> ADDRESS N" 9�I�r f� Lz,,1oD !2'X, CENSUS TRACT <br /> l e r's Name l.'7 �� l ' %� <br /> Phone <br /> 3 7 <br /> f City <br /> tractor's Name 1 1 y' <br /> License jb j7 <br /> OF WORK (Check) : NEW WELL I DEEPEN -/7 RECONDITION /7 DESTRUCTION /_7PUMP INSTZLATION /ZPW REPAIR -IIPUPOther 7. REPLACEMENT / <br /> 7 <br /> INCE TO NEAREST: SEPTIC TANK SEWER LINES z�_ PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PITT .9 -OTHg}Z <br /> PROPERTY LINEK�PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE t'YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial— Cable Tool Dia, of Well Excavation <br /> _ Domestic/private �/ Drilled <br /> Domestic i"'�' Dia. of Well Casing .41 <br /> /public <br /> Irrigation Driven Gauge of Casing <br /> _ r-- <br /> Gravel Pack Depth of Grout Seal /?_t <br /> _ Cathodic Protection _� Rotary Type of Grout <br /> _Geophysical <br /> Disposal -� Other Other Information \ <br />, <br /> Surface Seal Installed BX: , <br /> G <br /> FNSTALLATION: Contractor /7/JY ''�. �' ' •• -� �' <br /> F <br /> Type of Pump <br /> _ <br /> H.P. <br /> IEPLACEMENT: / / State Work Done <br /> ZEPAIR: / ,/ State Work Done \ <br /> XTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> :by agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> :e State of California pertaining to or regulating well "construction. With <br /> in I� completion of my work on a new well., I will furnish the San Joaquin Local Health�D s EN DAYS <br /> RILLERS REPORT of the well and notify them before putting the..well in use.. The aboverict a <br /> ation is true to the best of my knowledge and belief. I WILL CALL FOR A <br /> TO GROUTING AND A FINAL INSPECT GROUT INSPECTION_ <br /> PLOT' PLAN ON REVERSE SIDE � - <br /> 1 <br /> FOR DEPARTMENT USE ONLY / <br /> I <br /> TION ACCEPTED BY DATE <br /> ONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ; <br /> TION BY DATE ,= INSPECTION BY nATI? % ' '_ • , <br />