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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466-6781 lq' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7-1 . <br /> .- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;3-4-'2 <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br />[ Phone <br /> Owner's Name <br /> City <br /> Address s <br /> Contractor's Name - License Phone <br /> k TYPE OF WORK (Check): NEW WELL.L-7 DEEPEN /� RECONDITION 1-7 DESTRUCTION L7r"r <br /> PUMP INSTALLATION Z PUMA' REPAIR / / PUMP REPLACEMENT I I <br /> Other <br /> DISTANCE••TOuNEAREST•:—SEPTIC-TA NK= — SEWER-LINES <br /> SEWAGE DISPOSAL FIELD CESSPOOL'/SEEPAGE PIT OTR ^_ <br /> PROPERTY LINE - PRIVATE DOMESTIC ML—L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia,of Well. Excavation <br /> Industrial , <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 <br /> Protection Rotary pe, of Grout ' <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> �.- c <br /> PUMP INSTALLATION: Contractor <br /> Type..of Pump H.P. <br /> L <br /> PUMP REPLACEMENT: . /�/ --State Work Don s <br /> G PUMP .REPAIR: VL / <br /> State Work Done t. <br /> DESTRUCTION QF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> , k <br /> I .-hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dlatrict <br /> and the State.of California pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 o the best o€ my knowledge and belief. I WILL FOR A GROUT CTI4i; <br /> PRIOR TO GROUTING ARD A FI AL INSPECTION. TITLE � 13 <br /> r SIGNED LLAW PLAN 'ONIRSE SIDE 1 , <br /> FOR DEPARTMENT. USE ONLY 7A <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATB��` `., <br /> ADDITIONAL {:ObOMTS: PHASE II PI13AL INSP$CTI0�1 <br /> PHASE II G INSPECTION DATE <br /> INSPECTION BY INSPECTION BY <br /> 4 3x76 <br /> E H 1426 Rev. 1-74 - <br />