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A4 <br /> SAN JOAQUIN LOCA HEALTH DISTRICT <br /> FOP OFFICE ,USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> 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 222-- 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ OCA?ION � � � r SUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> ( & 7 4a y <br /> Co'ntractor's Name Q t�tlh'1fl License Phone le <br /> r� <br /> _ I <br /> TYPE OF WORK (Check) : NEW WELL � DEEPEN '/ / RECONDITION /� DESTRUCTION //_7 � <br /> PUMP INST LATION / PUMP REPAIR / / PUMP REPLACEMEN-T /_7 VOther / / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES , -4-PIT PRIVY <br /> SEWAGE DISPOSAL RELID CESSPOOL/SEEPAGE,.PIT Z -OTHER <br /> w - PROPERTY 5JOPZVTE DOMESTIC WEL- 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 �"L Driven Gauge of Casing l�\ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other Information <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor ) <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth e <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric. <br /> and the State of California pertaining to or regulatingwell -construction. Within FIFTEEN DA's ` <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <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 INSPECTIOD _ <br />'RIOR TO GROUTING AND A FINAL INSPECTIO .1=:Q <br /> SIGNED ,ITLE <br /> (D OT P IAN REVERSE SIDE) j <br /> FOR DEPART NT USE <br /> PHASE I ONLY <br /> APPLICATION ACCEPTED BY �~ DATE <br /> ADDITIONAL COMMENTS: If <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATEc1' INSPECTION BY DATE /f -/ 77 <br /> H_IA9F n .. , moi. 1177 : 9M <br />