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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0—A OFFICE USE: - .1601 E. Hazelton Ave. , Stockton, Calif. ©�]_ /?0^, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 a7 S7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �i (Complete In Triplicate) <br /> Application is hereb 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 Ordinances No 1862 an e.Rules and Regulations,of t San Joaquin Local Health District. <br /> JOB ADDRESS/1.0 <br /> ON c,L,UI< EtAr44 CENSUS TRACT <br /> Owner's Name Phone <br /> Address 04 'IA <br /> n , city <br /> Contractor's Name Sa License / Z2rPhone t22 -' <br /> R <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN 17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /)-e7 PUMP REPLACEMENT /J" <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 4 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: pc7 State Work Doneaal=a i� <br /> ES•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 putting—the— well in use.. The above <br /> information is true to the-best of my knowledged elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AN A FINAL CT-�W. L�I <br /> SIGNED - 'ON. : L <br /> ITLE <br /> j(DPLOT PLAN ON6�RSE SIDE <br /> FOR DEPAR T USE ONLY . <br /> PHASE I _ _ <br /> APPLICATION ACCEPTED BY -. ! DATE s <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT_ INSPECTION_ P S FI INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE .� <br /> 5w <br /> E H 1426 Rev. 1-74 1-74 2M <br />