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Ca,- 10 4 �! SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FqE OFFICE SE: ` 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 7�_ Z <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION' D"7'"T Q4Q ac CENSUS TRACT 14f-7fo-o( <br /> Owner's Name Phone <br /> Addressf �' <br /> -So AVO a City .?'�-�a�� <br /> Contractor's NameLicense # <br /> ),�PhoneOr- <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other /% N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER h <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 I <br /> _ Domestic/private Drilled Dia. of Well Casing -� J <br /> Domestic <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �j <br /> i Cathodic Protection Rotary Type of Grout <br /> 4 Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump a H.P. <br /> PUMP <br /> State Work Done �� � <br /> PUIV .EtEPAIR: /7 State Work Done _ <br /> E&TRUCTION OF WELL: Well DiameterPi <br /> Describe Material and Procedure Approximate Depth <br /> � IF <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 j <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-a d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL INSPE ON. <br /> SIGNED TLE <br /> 8 l!` (DRAW PLOT PLAN ON REV8RSE SIDE) <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY r DATE 7� <br /> E H 1426 Rev. 1-74 . <br /> 1_71L 9M <br />