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SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> FOAfOFFICE USE: f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a//-T,; <br /> ' (Complete In Triplicate) <br /> Application is 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - 15,9a a�q CENSUS TRACT <br /> Owner's Name (_ &2 IV CrI11AL Phone <br /> Address�w C� City <br /> Contractor's Name �. S�17tpy� ,�'�„J License # )V Phoned-a? U7 <br /> -TYPE OF. WORK (Check): NEW WELL /? DEEPEN J-7 RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION / •/ PUMP REPAIR 4 PUMP REPLACEMENT <br /> r Other / 7 <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/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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump .. .F H.P. <br /> PUMP REPLACEMENT: / / State Work Done .F <br /> "PUMP`'REPAIR "..'�"�' '.fes -State Work Done' <br /> !!off +. <br /> �. <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe-Material- and Procedure <br /> Y hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the LState 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 FQA A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A F AL SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID-E44ei:i4 i - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .. D <br /> A /Q-2 S� <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION RASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY <br /> t E H 1426 Rev. 1-74 <br />