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SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> FOAjOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif.. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 ,E/ 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE pISSUED 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 isi;made in compliance with San Joaquin' <br /> County Ordinance No.. 18.62 nd,the.-Rules and Regulations of the 'iSan Joaquin Local Health District. <br /> �� COP � - <br /> JOB ADDRESS/LOCATION /7,0,6 - ! l°f�f (i ("'CENSUS TRACT <br /> Owner's. Name. , r G!� e Gf Phone ;�?,/- <br /> Address D City 1ti <br /> Contractor's Name ! Licenseone <br /> _ N <br /> TYPE OF WORK {Check}: NEW WELL/? DEEPEN '/RECONDITION / '� DESTRUCTION �f � <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ I;PUMP REPLACEMENT /-7 <br /> l� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY m <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEE`PAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 0L WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well; Excavation <br /> —� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Information <br /> GeopSurface Se <br /> h sical Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .RREPAIR: /? State Work Done <br /> RESSRUCTION 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 S,,an 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 GR U ING AND FINAL INVZPyION. <br /> SIGNED TILEPe <br /> > (DRAW PLOT PLAN ON DE602 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . � r <br /> APPLICATION ACCEPTED BY DATE/ <br /> ADDITIONAL COMMENTS: < <br /> PH&U II 9RQUT JWSPECTION PHA -III FINAL INSPECTION <br /> INSPECTION BY 7 E1.4 ..s-7 INSPECTION. BY. TE <br /> G3 E H 1426 Rev. .1-74 1-74 2M- <br />