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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh'r�OFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7-V _35__/&) <br /> THIS PERMIT EXPIRES.F1 YEAR FROM DATE ISSUED Date Issued _ 90 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit -to to <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 /> Ago <br /> JOB ADDRESS/LOCATION _4716AAC B' !P1 CENSUS TRACT <br /> Owner's Name <br /> Phone � <br /> Address Ji � t <br /> City' J <br /> Contractor's Name 9 d�f r <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL /�C�II$EPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> ' PUMP INSTALLATION / UAP REPAIR / / PUMP REPLACEMENT f7 <br /> L Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 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 <br /> I dustrial able 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 Other Other Information <br /> Geophysical ^'"`-'"' <br /> _ Surface-Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump :i <br /> . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <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 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-beat of- my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GRQjqINQ.AND A FINAL INSPE ON. <br /> SIGNED TITLE f <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FbR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 4� <br /> ADDITIONAL COMMENTS: 1. Eggj - 5a le <br /> H.sf a <br /> PHASE II G OUT INSPV2 TION 'HAS III/LINAL INSPECTION <br /> INSPECTION By DATE w.7 INSPECTION. BY TE <br /> -70 <br /> 1E H 1426 <br /> Rev. 1-74 1-74 2M <br />