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SAN JOAQUIN LOCAL HEALTH •DISTRICT <br /> FOR OFFICE USE: 1.601 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 I YEAR FROM DATE ISSUED Date Issued <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of� the San .Joaquin Local Health District, <br /> JOB ADDRESSILOCATION CENSUS TRACT '1 <br /> qq s <br /> Owner's Name L0 7�` Phone <br /> 4 <br /> F. City <br /> Address- - N 0 AIV <br /> Contractor's NameZZLtf &L # /.3 9 Phone� J& <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 � <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> T a <br /> Other <br />'C DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES /pD r PIT PRIVY Z61 <br />` SEWAGE DISPOSAL FIELD C04 / CESSPOOL/SFJ✓PAGE PIT OTHER <br /> PROPERTY LINE/d PRIVATE DOMESTIC WELL Y PUBLIC DOMESTIC WELLtA <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �•; <br /> Industrial Cable Tool Dia. of Well_Excavation r <br /> Domestic/private Drilled Dia. ofLW611` Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .'- Gravel Pack Depth of. Grout Seal <br /> 4 <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 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> he San Joaquin Local Health District <br /> 3 I hereby agree to comply with all laws and regulations of t q <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 G U TNG AND A FINAWYbECTION. <br /> SIGNED TITLE <br /> ?!EE(DRAW:�PLOYrPLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION P E I/ AL INSPECTION <br /> INSPECTION BY DATE d .3/ 7� INSPkCTION BY �� DATE , ® <br /> 7 7 . .2M <br /> E H 1426 Rev. • 1--74 <br />