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SAN JOAQUIN,LOCAL HEALTH- DISTRICT <br /> FOR OFFXE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7M, psyo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _M--7e1 <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�l'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 V-0 y' Ca ry,o CENSUS TRACT <br /> Owner's Name '� �� � Phone <br /> Address D City <br /> Contractor's Name License # If3 —Phone ' <br /> i <br /> TYPE OF WORK (Check) : INEW WELL / / DEEPEN/_/ PRECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT <br /> IOther / / <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 i' Rotary Type of Grout ' <br /> Disposal OtherOther Information <br /> Geophysical T Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> :Type of Pump H.P. <br /> PUMP REPLACEMENT: . / State Work Done <br /> PUMP .REPAIR: Imo/ State Work Done <br /> I�. <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 Vocal 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 <br /> PRIOR TO OUTING AND A��FIN I EVYWf. c� <br /> S IGNEZ NY TITLE <br /> iI DRAW L O T' PL RE FRSE SIDE) <br /> 4 <br /> FOR DEPARTMENT USE ONLY { <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ul�� , } <br /> PHASE II GROUT INSPtCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �^ .DATE /� I <br /> E H 1426 Rev. 1-74 3/76 2M <br />