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JIJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01~ OFFICE USE: 1.601. E. Hazelton Ave. ., Stockton, Calif. � <br /> Telephone : ('209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 `. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued MAY 2 4 197$' <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 /> f.4 7 � �5S-cgv-zo <br /> JOB ADDRESS/LOCATION <br /> Owner's NamePhone T <br /> Address / a4)-f Co-, City <br /> Contractor's Name tA- +.e" License 11*7 Phon JJ <br /> a <br /> TYPE-OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INST EATION f / PUMP REPAIR / f PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER`LINES- PIT PRIVY <br /> SEWAGE: DISPOSAL FIELD C POOL,SEEPAGE PIT OTHER <br /> PROPERTY LINE�.�'PRIVATE UOME_ STI_C_ WELL -PUBLIC DOMESTIC WELL k <br /> INTENDEDUSEA TYPE. OF WELL CONSTRUCTION SPECIFICATIO <br /> Industrial Cable Tool Dia, of Well Excavation r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> vs, <br /> Disposal Other Other Information <br /> Geophysical Surface .Seal Installed By: <br /> PUMP INSTALLATION: Contractor dun <br /> Type of -Pump H.P. e <br /> 4 PUMP REPLACEMENT: / / State`Work Done ., <br /> I` <br /> PUMP .REPAIR: / / State Work Done -` <br /> DES-TRUCTION 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 REPORT of the well and notify them before puttingthewell 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 /> a (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III,/-FINAL INSPE BION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> q t)/77 _ 2M C <br /> E H 1426 Rev. . 1-74 <br />