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fo X? SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601. E. Hazelton-Ave. , Stockton, Calif. I(/ <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - <br /> l <br /> THIS PERMITYEAR FROM DATE ISSUED <br /> _ EXPIRES 1 Date- Issued /� �'� <br /> , • <br /> (Complete In Tri-plicate) <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. Distri.ct. <br /> JOB ADDRESS/LOCATION -— � � /V CENSUS TRACT <br /> Owner's Name fill Phone <br /> Address - L el'io City <br /> Contractor's Name License # :_j.2;�j'Phone " -74.?1- <br /> ^� <br /> — a <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN - / RECONDITION 1._I DESTRUCTION /_7 <br /> PUMP INSTALLATION 1, PI1MP REPAIR % / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES PIT PRIVY i <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 U <br /> X Domestic/private Drilled' Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <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 H.P. ' <br /> PUMP REPLACEMENT: / StateWorlc Done /4' , <br /> PUMP REPAIR: / / State Work Done <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. Wi.thin\,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 o knowle. nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OU ING D A FINAL-INSP <br /> SIGNED .22 TLE , <br /> RAW OT PLAN ON PSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /D-7- 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE.-JI FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE & . zz <br /> . _ 2M <br /> E H 1426 Rev. - i-74 b177 <br />