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•� SAN JOAQUIN LOCAL,;MALTH DISTRICT " <br /> FOgrOFFICE USE: - 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 3 6� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ; �.J= 22-7-0ZO -0 <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 arkd the Rules and Regulations of the San Joaquin Local Health District. y <br /> F5 Ec��v-�q- .�' 4 � 1'tin i �d�s� d� CENSUS TRACT � �L <br /> JOB ADDRESS/LOCATIO� <br /> -�. - t <br /> Owner's Name �, Phone <br /> Address City_ <br /> Contractor's, Name License Phone <br /> o�R0.9/3 <br /> TYPE OF WORK (Check) : NEW WELL/yl DEEPEN/_7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT I r � <br /> Other ET <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 TYNE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Industrial <br /> 17 <br /> Domestic/privateDrilled Dia. of Well Casing <br /> __DomesticJpublic.� --Driven - Gauge of Casing "" { <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' AW <br /> Disposal Other _ Other Information 1' <br /> GeophysicalSurface Seal Installed B' : <br />` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> h <br /> f PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: L_T State Work Done <br /> ES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 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 knowledge and belief. I WILL CALL FORA GROUT INSPECTION . <br /> PRIOR TO GROUTING AN INAL IV$PE.CTjON. <br /> SIGNED TITLE <br /> (D PLOT LAN ON REV SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> Al <br /> PHASE I 4G� W L�,� T/o v S ! <br /> APPLICATION ACCEPTED BY O �✓ DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> + INSPECTION BY DATEy)._t1AA1j __. INSP CTION BY DATE <br /> 1 <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />