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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPiiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7c <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued 7-ZS-�y� <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 /> :TOB•ADDRESS/LOCATION C4J Ge= � CENSUS TRACT <br /> l Ownerts Name Phone 41(o / - <br /> 1 <br /> Address City , <br /> Contractorta Name16�� License aC 3�3 Phone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_7 RECONDITION -7 DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR PUMP REPLACEMENT rT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK wSEWERLINES PIT PRIVY, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' - PUBLIC DOMESTIC WELD:' <br /> INTENDED USE '-<TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ^ ._ CableJTool Dia._of Well Excavation <br /> 'Domestic/private Drilied "Dia. of Well Casing <br /> 4 Domestic/public :,z-' Driven Gauge of Casing <br /> IrrigationGravel 'Pack Depth of 'Grout Seal <br /> Cathodic Protections' Rotary' Type of Grout <br /> Disposal Other '--.Other Information <br /> Geophysical Surface Seal Installed By: . �- - <br /> F / <br /> PUMP INSTALLATION: '-Contractor !'-C. F <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j/7 State Work Done <br /> State`WoirkDone <br /> PES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> f 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 GROIjANR A F N INSPECT ON. ] <br /> SIGNED ��,� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> � �R DEFARTMENT USE ONLY ,�( <br /> PHASE I = <br /> APPLICATION ACCEPTED Y : r„ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEiIII/FTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY DATE <br /> 1� <br /> Fti E H 1426 Rev. 1-74 1-74 2M _ . , <br />