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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rOR•GFFIC USE: .11601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7j_s- ,r,�P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,j,-_ 9?7 <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 CENSUS TRACT ' <br /> Owner's Name d &LMJ, Phone <br /> AddressCi <br /> 3 [■\`,'� <br /> � ty <br /> Contractor's Name License #l -'Fhone _ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /Y-7 <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 U <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 v Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor v� - <br /> Type of Pump A .6 H.P. / <br /> PUMP REPLACEMENT: State Work Done g <br /> 4°— <br /> PUMP"REPAIR: / / State Work 'Done <br /> i� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> J <br /> I hereby agree to comply with all laws and regulationsof the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS 4 <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 knowledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL_jgSPEIO , <br /> SIGNED ITLE + <br /> (D P ;OZ -ON . RSE SIDE) <br /> E <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL -COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 'INSPECTION BY DATE _7 '7 7 <br /> E H 1426 Rev. 1-74 <br /> l f 77 2M <br />