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5 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F691'.OFFICE USE: 1601 E. Hazelton Ave: , 'Stockton, Calif. <br /> Telephone: ­(209)-~466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S--)41- <br /> THIS PERMIT EXPIRES I 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 A <br /> and/or .install the .vork herein described. This application. is made in compliance with San Joaquin <br /> County Ordinance No.7.1862 and the Rules and' Regulations'of .the San Joaquin Local Health District. <br /> t <br /> JOE ADDRESS/LOCATION 1 ]6HH '` s.: CENSUS TRACT <br /> Owner's Name' Phone <br /> ' Address I" ' a a � .1 .. - City <br /> i <br /> Contractor's Name y License # Phone <br /> TYPE OF WORK (Check): NEW WELL T7 DEE PE.N Y/� -.RECONDITION- /-7 DESTRUCTION /7 N -w <br /> PUMPNINSTALLATION / / PUMP REPAIR /- PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC,TANK . SEWER LINES PIT PRIVY <br /> •� SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> l...� PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE T'A'PE OF, WELL_ � _..:� �. t CONSTRUCTION SPECIFICATIONS <br /> Industrial,, Cable Tool Dia. of Well Excavation <br /> Domestic/private.- Drilled E Dia. of Well Casing <br /> Domestic/publW Driven Gauge of Casing <br /> Irrigation'. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type- of Grout <br /> Disposal r Other Other Information <br /> Geophysical .1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A l <br /> Type of Pump =­4 H.P. <br /> A. 1, <br /> PUMP REPLACEMENT: /77 State Work Done 1 u <br /> PUMP'RRPAIR: /7 State Work Done TAT <br /> —2KS TRUCTION-,OF-WELL: —'Wa11`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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �ac�nll.lrn �,aarw _ . I . TITLE `Q�]a a )M1 Aiyy�aonl "} <br /> (DRAW PLOT PLAN ON REVERSE SIDE 0 <br /> FOR JDEPARTus <br /> E ONLY <br /> PHASE I :. <br /> APPLICATION ACCEPTED BY / DATES <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT_ INSPECTION PHASE III/ SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />