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- SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> FORtOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - 75SW <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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. 1862 and the Rules Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION to AoO <br /> CENSUS TRACT <br /> Owner's Name Phone 72. <br /> I <br /> Address . City <br /> Contractor's Nance ` License _CQ40Phone� <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /_j- RECONDITION /_7 'DESTRUCTION %f <br /> PUMP INSTALLATION HP REPAIR /7 PUMP REPLACEMENT{ /7, <br /> Other _/ 7 <br /> DISTANCE TO NEAREST: SEPTIC TAN EWER'LxNES ;PIT PRIVY r { <br /> SEWAGE DISPOSAL FIELD � r � j"- <br /> .. - ._. SSPOOL/SEEPAGE`PIT •—v,y:OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION-SPECIFICATIONS <br /> ndustrial Cable Tool Dia. of Well Excavation <br /> + Domestic/private -Drilled Dia. of Well 1Casi.ng <br /> ' Domestic/-public _Driven:.; Gauge of Casing i <br /> Irrigation r _ Gravel Packer Depth of Grout Seal U <br /> Cathodic Protection e---fttary `"r Type of Grout <br /> Disposal ,- Other Other Information <br /> Geophysical i r <br /> rfa a Seal ailed B : ✓' <br /> r <br /> t <br /> PUMP INSTALLATION: Contractor '.' <br /> Type of H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: /-7 State-Work Doney _ <br /> E&TRUCTION OF WELL: Well Diameter <br /> t Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with 411 laws and regulations ,of} the San Joaquin Local Health Distract,,, <br /> and the State of California pertaining to or regulating well -construction. Within FIFTEEN DAYS <br /> after completion of my work on al�new well, I will furnish the San 'Joaquin Local Health District'. a <br /> WELL DRILLERS REPORT of the well '-and notifythem before g..� ' <br /> puffin the..well.in.uee.. The above -; r <br /> info tion is true t t es o my-knowledge and belief. I WILL CALL"FOR-A -GROUT INSPECTION <br /> PRIOR T ROUTING AN A N ION. , � <br /> SIG �1"' <br /> F�p <br /> TITLE ,p rid _��,�,•'k i <br /> ' DRAW PLOT PLAN ON REVERSE SIDEr <br /> FOR DE ARTMENT USE ONLY r <br /> PHAS <br /> APPLICATION ACCEPTED BY DATE Q <br /> ADDITIONAL:COMMENTS: <br /> PHASE II GEM INSPECTION, gp I N INSPECTI NINSPECTION BY � DATE i y � INSPECTION DATE s <br /> _ � �`L�/f .d��4Jy-%'� k t °;�r- ~``'w •�k <br /> �a/c��.✓- ,rev� dcu-"'d�.).---4 .��.r:,.r, 1-74 9MH1426 Rev. `74 � <br /> ! <br />