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SAN JOAQUIN LOCAL HEALTH DISTRICT � J + <br /> FOh OFFICE USE: ��" 1601 E. Hazelton Ave. , .Stockton, Calif. 'yy <br /> Telephone : (209) 466-6781 } <br /> 7-1��r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 + <br /> F ' <br /> i THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued 14"7- <br /> (Complete In Triplicate) <br /> Application is hereby mlde to the San Joaquin Local Health District for a permit to construct <br /> I and/or install the word 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 :ij �J f�! I CENSUS .TRACT <br /> Owner's Name Phone lJ 2 5' <br /> Address5A0 City <br /> 4714 <br /> �-]acpLi ens <br /> e Phon <br /> Contractor's Name f c 7�� <br /> TYPE OF WORK (Check) : NEW WELL " DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE-.TO NEAREST: SEPTIC- TANK Lo SEWER LINES PT PRIVY <br /> t 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 1[ Cable Tool Dia. of Well Excavation� � <br /> °Domestic/private 'j' Drilled Dia. of Well Casing ,� <br /> Domestic/public it Driven Gauge of Casing <br /> Irrigation I� 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: I;Contractor <br /> �TYpe of Pump H.P. <br /> .E <br /> PUMP REPLACEMENT: 1I/ / State Work Done <br /> PUMP".REPAIR: 71/-/ State Work Done <br /> f �I— <br /> ' DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ;;; <br /> Describe Material and Procedure <br /> I hereby agree ree 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 my1work on a new well, I will furnish the San Joaquin Local Health Distract 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 lb TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> fa i� FOR DEPARTMENT USE ONLY <br /> PHASE .I ,, DATE / C/ <br /> APPLICATION ACCEPTED BY <br /> t ADDITIONAL COMMENTS: <br /> PHAS GRO T INSPECTION PHASE III/FINAL INSPECTION <br /> 17 <br /> INSPECTION BY DATE �7 INSPECTION BY DATEW <br /> 72M - <br /> E H. 126 Rev. , 1-74 "� <br />