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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L:OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif.FOF� , <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT,. Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued JOS-7-75 <br /> (Complete In Triplicate} <br /> Application is hereby made tolthe San Joaquin Local ilc.alth District fora pliant to construct <br /> and/or install the.work herein described. This application is made is compliance with San J . ' <br /> County Ordinance N . 1.862 andlithe Rules and Regulations of the San Joaquin LocaX Health Dnstrictict <br /> �i <br /> JOB ADDRESS/LOCATIc CENSUS TRACT <br /> Owner's Name r <br /> Address Cityr <br /> ��. 73Phone <br /> Lncadse ` F <br /> Contractor's Na <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPE!LL RECONDITION I T DESTRUCTION f7 , �. <br /> PUMP INSTALLATION / / PUMP REPAIR '/? 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'—. 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/publicDriven Gauge of Casing <br /> Irrigation <br /> _ Gravel, Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> . <br /> Disposal V Other Other Information ' <br /> Geophysical Surface Seal Installed 'By: <br /> r f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - s H.P. <br /> 7' PUMP REPLACEMENT: State Work �: _ ""_-4 <br /> I <br /> PUMP ,.REPAIR: / / State Wox _Done. *' <br /> DESTRUCTION OF WELL: Well-':Diameter f 'Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations, of the San Jdaquin Local Health District <br /> and the State of California pertaining to or regulating well'constructiou. Within FIFTEEN DAYS <br /> after completion of my work.on anew well, I will-,"furnish the .San Joaquin Local health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the_welk in.use .The above <br /> information is true to the best of my..knowledge,and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED TITLE X71 w�A_e sl <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEP HENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: PHASE III INAL INSPECTION <br /> PHASE II GROUT. INSPECTION DATE Z2 /S-7� <br /> INSPECTION BY DATE INSPECTION BY <br /> �, 2Ai <br />