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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 -/a� . <br /> Q' THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued �f-lS r)7 <br /> a ' '"-` (Complete In Triplicate) <br /> Application ifi 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 Ordinance No. 8(j gdthe $ules and Regulations of the Sam Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION U-) r CENSUS TRACT <br /> Owner's Name Phonec7v <br /> Address City <br /> Contractor's Name -<y <br /> � r Licende Phone�7 4/- <br /> t <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN ./7 RECONDITION /7 DESTRUCTION j� <br /> PUMP INSTALLATION PUMP REPAIR I PUMP REPLACEMENT <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' PUBLICDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation Z � ; <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 0- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _At Rotary Type of Grout <br /> Disposal Other Other Information �. <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done'* _ <br /> DESTRUCTION OF WELL: Well Diameter, !p Approximate Depth 2Q <br /> Describe Material and Procedure <br /> I hereby- agree to comply with all laws and regulations%ofathe. 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION s; <br /> PRIOR TO GROUTI& ANPA FINAL I ECTION. <br /> SIGNED 'TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE U <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , -,7 <br /> ADDITIONAL COMMENTS: <br /> PMME II G OUT INSPE ION . PHAS& III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br />