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e,S^ W SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF70FF1 E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �' 35�/a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 REAR FROM DATE ISSUED Date Issued S6 <br /> SfS'f �h° c'f'"ey° p-J. (Complete In. Triplicate) 201- v5'o—off <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> rind/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 &A j2 3 *:� Oed 14' MK Y*A.t�/� +r� CENSUS TRACT <br /> Owner's Name a�aa a Phone .. <br /> 4 <br /> Address ,.5��� atGJ"/o�1,•/ ,_ City <br /> Contractor s <br /> License # '1 f_$7A4Phone 2 L <br /> TYPE OF WORK (Check): NEW WELL /_T DEEPEN T7 RECONDITION f7 DESTRUCTION <br /> PUMP INSTALLATION /-7—PUMP REPAIR / / PUMP REPLACEMENT / T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (T1PROPERTY LINE - PRIVATE DOMESTIC WELL'* 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 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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _3CL — <br /> PUMP REPLACEMENT: / / State Work Done "f <br /> PUMP .REPAIR: State Work Done c <br /> ' DES•TRUCTION 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, 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-be'st of knowledgeand, belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJJTING AND A FINAL'INSPE 0 <br /> SIGNED TLE <br /> fi— T LAN OT RERSE SIDE <br /> tor ._O,*OR DEPARTMENT USE ONLY <br /> PHASE I' DATE , <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE ' <br /> Z► 2M <br /> E H 1426 Rev. 1--74 <br />