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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFSrOFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 =/3� <br /> 7V y�"° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued t� Zd_T <br /> (Complete In Triplicate) A <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 /> r <br /> JOB ADDRESS/LOCATION `L © CENSUS TRACT <br /> Owner's Name } Phone S E - Z©s q <br /> Address 2 7b ASO /V _ City <br /> Contractor's Name License #), Q_7qd� Phone 6 6 <br /> TYPE OF WORK (Check): NEW WELL / � DEEPEN '/� RECONDITION /� DESTRUCTYON /-T <br /> PUMP INSTALLATION X/ PUMP REPAIR f_1 PUMP REPLACEMENT /7 <br /> Other / / r_ <br /> Vt <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 `f <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 0A I <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other._ Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor (T <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:' / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br /> , ,RESjRUCTION OF W9LL: 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 <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 TITLE <br /> (DRAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO <br /> =. X� ROUT INSPECT ON P INAL TNSPFiCTIO _ <br /> YNSPECTY BY DATE INSPECTI DATE -S - 7.5 <br /> F1-7 4 2M <br /> E H 1426 Rev. 1-74 <br />