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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone; (209) 466-6781 <br /> AP LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-&S_fp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5B t;- y <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 d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C+� CENSUS TRACT <br /> Owner's Name _ -1 <br /> Phone <br /> Address <br /> -- — <br /> City <br /> Contractor's Name License Phone # <br /> _ I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> i <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 Q)� <br /> Domestio/private Drilled Dia. of Well Casing d; <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout I <br /> Disposal Other Other Information . <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. F <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION 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 DAIS <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 knowledge and belief. I WILL C41j, FOR A GROUT INSPECTION <br /> PRIOR TO G UTING FINAL INSPECTION. <br /> SIGNED TITLE Cry <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR D ARTMENT USE ONLY <br /> PHASE I 7// <br /> APPLICATION ACCEPTED BY DATE '�e// <br /> ADDITIONAL COMMENTS: Af <br /> PHASE Ii 4ROUT INSPECTION P.HASjo,"Iff-IN41 INSPECT 0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> F W lL?A n __ 1177 Om <br />