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� : - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FU"GT.FICE. USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> --,w. Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT— Permit Na. 7 <br /> THIS PERMIT EXPIRES I.YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orinstall the work herein described. This application is made incompliance with San Joaquin <br /> CountypOrdinance No. 1862 and the Rules and Regulations of the San-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '' x --CC4z_ /- : CENSUS TRACT,' <br /> Owner's Name PhonefU <br /> - w <br /> r <br /> Address <br /> g s- City <br /> C L � � - � <br /> 3 1 <br /> Contractor's Name License .#� <br /> Rhone �- � <br /> TYPE OF WORK (Check) : NEW WELL /i: DEEPEN / / RECONDITION_/ / DESTRUCTION /_7 <br />' PUMP INSTAUI.ATION / / PUMP REPAIR / / PUMP REPLACEMENT IJT <br /> Other <br /> DISTANCE�TO NEAREST: SEPTIC TANK /SEWER LINES PIT PRIVY µ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S EPAGE PIT OTHER <br /> `> PROPERTY LiiE36 DOMESTIC WELL el PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF- ELL', CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cab1 -"Tool Dia. of Well Excavation MW 7� It <br /> �mesti:c/private Drilled Dia. of Well Casing <br /> Domestic/pubes _—Driven �- Gauge of-Casing . �. <br /> FlrigaMari Grav"e l` Paclt Depth of Grout Seal""" <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. _ Surface Seal Installed Ii <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP�,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ~ Approximate Depth <br /> �— Describe Mater aJ and Procedure- <br /> k I 'hereby agree to comply with all laws and regulations of the 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 IN <br /> PRIOR TO GROU INGAN A FI NA T PECTTON. `T <br /> SIGNED TITLE ,. <br /> (DRAW PLOT PLAN ON REVERSE' SIDE) " <br /> FOR DEPARTMENT SE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY DATE �( /� _� <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ,. �'�` DATE-r-,2-.3_ <br /> i� INSPECTION BY DATE j 2� � �_- INSPECTION BY <br /> 2M /�{{ <br /> E H 1426 Reu. .��-7.4 <br />