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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _„OE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.l'? - 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) t <br /> . ,plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Mond/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin L cal Health District. <br /> ,..oB ADDRESS/LOCATION Zi 7d CENSUS TRACT <br /> i ner's Name Phone <br /> Address //4 �s� j.�Gx c� City <br /> ­ntractor's Name /� � License # Phone <br /> 'PE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION / _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / 0 <br /> ,.STANCE 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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 /> -TMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PJW REPLACEMENT: / / State Work Done <br /> ?UMP .REPAIR: / / State Work Done <br /> S•TRUCTION OF WELL: Well Diameter / / Approximate DZ'W',gV th 3d _ d <br /> Describe Mat'prial and rocedure <br /> hereby agree to comply wit all laws and regulatiofis of the San Joaquin Local Health District <br /> ,mid 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 /> ";LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Zformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> MIOR TO GROUTING AND A FIND INSPECTION. ,h <br /> SIGNED TITLE �d <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ?PLICATION ACCEPTED BY '-77:�j DATE <br /> .)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 4SPECTION BY DATE INSPECTION BY DATE <br /> i7 <br /> F N 1L9A moo„ 1_7A 3/76 2M <br />