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SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7 -- J� <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED 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 is made in compliance with San Joaquin <br /> County Ordinance No. 18`62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB.ADDRESS/LOCATION ✓ �J ?� CENSUS TRACT <br /> Owner's Name ? <!g7 Phonq L/ <br /> Address / ")g City <br /> Contractor's Name 5 License 4/c2- 37�Ohone'4449976ar' <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN /_7 RECONDITION 1-7 DESTRUCTION Jf_j <br /> PUMP INSTALLATION /_7 PUMP REPAIR PUMP REPLACEMENT f7 <br /> Other /:JJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <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 /> Industrial Cable 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done `I <br /> -PU1+0'REPAIR; ——­77-State Work Done We_z_ <br /> v <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW LOT PLAN ON REVERSE SIDE ' <br /> /YOR DEPARTMENT USE ONLY <br /> PHASE I J <br /> APPLICATION ACCEPTED B <br /> Y DATE <br /> ADDITIONAL COMMENTS:PHASE+ II N PHASE III FINAL INSPECTI N <br /> WSPECTION BY DATE INSPECTION BY DATE 5 <br /> E H 1426 Rev. 1-74 I-74 2M <br />