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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif.' <br /> Telephone : (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> 41 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued C 20 19)T <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 /> JOB ADDRESS/LOCATION I` ] Al, f CENSUS TRACT <br /> Owner's Name J49 ►/ 4A)6 N4 Phone <br /> Address /4y 7Y Al. Ox v/ s City /!/p/ - <br /> Contractor's Name Ir W ff' License # 746,02 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR f / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT M OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation 17- <br /> Domestic/private <br /> 7Domestic/private Drilled Dia. of Well Casing ;C <br /> Domestic/public Driven Gauge of Casing j \t <br /> Irrigation Gravel Pack Depth of Grout Seal V <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 / / State Work Done <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. 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 R T f t w1 and notify them before putting the well in use.. The 'above <br /> informati is t t of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR GROUT S CTION. , <br /> SIGNS TITLE <br /> PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHAS I / <br /> APPLICATION ACCEPTED BY rave - DATE '" r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E B 1426 P,. 17-7-4 - 1177 '2M <br />