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SAN TOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 I iazelton Ave. , Stockton, Calif _ <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7,-;,-./ yy j <br /> (oP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -o p. -7� <br /> (Complete In Triplicate) <br /> _ication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .;or install the work herein described. This application is made in compliance with San Joaquin <br /> inty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ADDRESS/LOCATION ���U/ /�� /P�,�/1� CENSUS TRACT <br /> >_r's Name 2Z L 174 ^�5Z-A/ Phone 9, 3 � Q <br /> Tress City .STA TIY <br /> T=ractor's Name I ' License Phone -z <br /> i <br /> E OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> -rANCE TO NEAREST: SEPTIC TANK / O 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 /> --I)omestic/private Drilled Dia. of Well Casing \ <br /> — Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea 'eI <br /> _ Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> P INSTALLATION: Contractor \J <br /> _ Type of Pump H.P. <br /> P REPLACEMENT: / / State Work Done <br /> P REPAIR: / / State Work Done <br /> — a <br /> r <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> e: the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ;ormation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> COR TO GROUTING D A FINAL INSPECTION. <br /> ,NED /J TITLE <br /> rt <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY <br /> ".SE I <br /> 'LICATION ACCEPTED BY [i DATE <br /> DITIONAL COMMENTS: <br /> PL -GR UT_INSPECT ON PHASE LkV F INSPECTION <br /> ;PECTION BYDATE INSPECTION BY DATE ll—,,2 i"j <br />