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C"40 <br /> � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OF'FICE USE: 1601 E. Hazelton Ave. , ' Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S Sa 7p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued {j_,7_,7 ' <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 Rulesand Regulations of the San Joaquin Local Health District.. ' <br /> JOB ADDRESS/LOCATION C. ' I K 4 ,11 CENSUS TRACT i <br /> Owner's Name �; Phone <br /> Address City <br /> Contractor's Name ah0Low. License Q 37yJ phone GZ 74 76 <br /> TYPE OF WORK' (Check): NEW WELL /7 DEEPEN '/-7 RECONDITION ff DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE -.PRIVATE DOMESTIC WELT. iPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia. of Well Casing �I <br /> Domestic/public- . , , . Driven Gauge of Casing' r <br /> ' Irrigation Gravel Pack Depth of Grout'seal `0 <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information " <br /> Geophysical , Surface Seal Installed By: <br /> e <br /> PUMP INSTALLATION; Contractor <br /> r <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 j <br /> Describe 'MaterialRand -Procedure s <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.Vell. in.use.... .The above ' <br /> information is true to-the,best.o - my..knowle d belief. I WILL CALL FOR A 'GROUT INSPECTION !! <br /> PRIOR TO GROUTING AND A FINAL IN E ON <br /> SIGNED a,�r TITLE <br /> P T PLAN ON IWVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE V' 6 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION {+ <br /> INSPECTION BY DATE YNSPECTION BYATE a -- <br />,� =ETH 1426' Rev. 1-74 - - r G/75 2M <br />