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- fU" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh• 0 FICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> I. Telephone : (209)• 466-6781 <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) <br /> Application s reby 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 /> JOB ADDRESS/LOCATION e CENSUS TRACT <br /> VWEOwner's Name ft� llV" ~ hone ' <br /> �-y��f t r <br /> Address 7"7'Sf , City <br /> Contractor's Name License # ,,&&3P h o n e <br /> f <br /> T <br /> L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A g14AJ, INSPECTI N. <br /> SIGNED TITLE <br /> (DW PLOT PLAN -REVERSE SIDE)PHASE I . <br /> FOR DEPARTMENT USE ONLY -� f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, /FINAL INSPECTIO <br /> INSPECTION BY DATE �2./�, 7INSPECTION BY DATE <br /> E x 1426 Rev. 1-74 _ — /. <br />