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SAN JOAQUIN LOCAL HEALTH DISTRICT -Z z-7�11 <br /> FOR•+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. F <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 Issuedc� <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 <br /> k'7 d244 CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address City �'%� o h <br /> 'T 4 <br /> Contractor's Name fi r „ 4 License # Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/_ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / J PUMP REPLACEMENT 17 <br /> Other J / <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 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> :7�_ Domestic/private Drilled Dia. of Well. Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> 3 Irrigation Gravel Pack Depth of Grout Seal a <br /> Cathodic Protection r1,-- Rotary Type of Grout <br /> Disposal Other 0 In rmat vv� <br /> - Geophysical (,V'T P� f :e �-1 taped B <br /> v. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP !REPATR: /_T State Work Done <br /> E$TRUCTION 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 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 <br /> PRIOR TO EE2HE&NG AN AFI INSPECTION. <br /> SIGNED TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDEr— -, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -4, <br /> " PHASE ITeg T P ON ' ' PHASE II FINAL-INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY 'DATE .off <br /> R E H 1426 Rev. 1-74 � <br /> _ - Y... . 1=74 2M <br />