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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> VotF eOFFICE USE: I 11601 E. Hazelton Ave. , Stockton, Calif. ' <br /> _ Telephone: (209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7. _ 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete 1n 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 Sax: Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of 'the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION eJ IU r CENSUS TRACT <br /> ,N <br /> Phone <br /> Owner f OwnerQs Name Cr- T`froAl h,/n 6IK - <br /> Address 1 City 1 r <br /> � �--� <br /> Contractor's Name I� �`1 ' �.�cer►se � �$cL 3�Phone X77 3GA <br /> 4 <br /> TYPE OF WORK (Check) : �iNEW WELL DEEPEN/ / RECONDITION DESTRUCTION I-'T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> s DISTANCE TO NEAREST: '.SEPTIC TANKESEWER LINES IV PIT PRIVY <br /> .SEWAGE DISPO LFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS G4 <br /> Industrial _ Cable Tool Dia. of Well Excavation 0 <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 PTotecrion Rotary Type of Grout O <br /> } Disposal Other Other Information <br /> Geophysical Surface Seal installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-:REPAIR: '—/-7­-State Work Done_, <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> III Describe Material and Procedure <br /> a 1 <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 .w.ell in.use.. The above <br /> i information is true tt the best of my knowledge and belief. '1I WILL& FOR A GROUT INSPECTION <br /> k PRIOR TO AROUTIK ANDA FINAL INSPECTION. <br /> SIGNED JA 1TITLE <br /> i� (DRAW PLOT PLAN ON .REVERS'E SIDE <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED .B <br /> DATE <br /> ADDITIONAL` COMMENTS: I, x <br /> PHASE 11, 2LOUT INSPECTION ,, ' . PRASE II FINAL INSPEC ION 7 <br /> INSPECTION BY /` DATE �J INSPECTIN 'SY DATE f <br /> `1 E R 1426 Rev, 174 1-74 2M <br />