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�j SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> /-- <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ,�� <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued <br /> r ©.�� nl C�-t �:, (Complete In Triplicate) <br /> Application is hereb 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. 1662 and the Rules and Regulations of the San Joaquin Local Health District.' <br /> JOB ADDRESS/LOCATION C'; / �^ CENSUS TRACT <br /> Owner's Name <br /> Phone,�6 9- a 0 <br /> Address Cit <br /> Contractor's Name License #/6-2-27-3 Phone 3 <br /> qN <br /> TYPE OF WORK (Check) : NEW WELL RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP-INSTA•L-LATION-/7/-- PUMP-REPAIR 15 PUMP REPLACEMENT F7 <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 WELT, CONSTRUCTION SPECIFICATIONS <br /> 1.-_�ndustrialCable Tool Dia, of Well Excavation <br /> -- -----�"..- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ _ _,Q) <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic' Protection Rotary Type of Grout <br /> F Disposal Other Other Information <br /> Geophysical Surface Seal` Installed By: <br /> i PUMP INSTALLATION: <br /> :Contractor: <br /> of PumpH.P.PUMP REPLACEMENT: ,�Type <br /> � State Work Done <br /> PUMP .REPAIR: /� State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby agree to comply, with all lams 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 best of my . nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D All INSPE ION. <br /> SIGNED ,i. TITLE <br /> PLAN ON REVERSE SIDS " 'r-�- r-----�-r�: <br /> � . FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY� DATE 3 J� <br /> ADDITIONAL COMMENTS: I' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION/ <br /> INSPECTION BY IM: DATE INSPECTION BY - <br /> DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />