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r� SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOA,UF__F USE: 1601 E. Hazelton Ave.':, Stockton, Calif. <br /> Telephone (209) .46&.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S 7/X-- <br /> THIS PERMIT EXPIRES I;YEAR FROM DATE ISSUED Date Issued 3-7.5� <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 Joaqui: <br /> County Ordinance No. 1862 and the� Rules and Regulations.. of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION &A00q-t,&1 ,. �,c.s, b` S TRACT <br /> Owner's Name C.� -C.tt.r{,� Phone <br /> Address r City .�...... .� <br /> Contractor's Name License Phone d� f <br /> TYPE OF WORK (Check).: NEW WELL/_7 DEEPEN /_7 RECONDITION /_7 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 <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL G <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 B <br /> PUMP INSTALLATION: Contractor 1 C0 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: � . State Work Done ?ZGc.ej <br /> PUMP '.REPAIR: IT State Work Done <br /> PE,STRUCTION 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, 1- will furnish the- San Joaquin Local Health District <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 FORA-GROUT INSPECTION <br /> PRIOR TO G UTING AND FINAL INSPECTION. <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN -ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �J <br /> APPLICATION ACCEPTED BY Z�A DATE <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-JIUFZ& INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE IC <br /> E H 1426 Rev. 1. 74 1-74 2M <br />