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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE- - 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE ISSUEDDate Issued `3 '7 <br /> (Complete In Triplicate) <br /> Application isiereby n4ade 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 Mau &=0ZEeltCENSUS TRACT <br /> Owner's Name Phone l- f �2 <br /> f Address. Cit <br /> Contractor's Name .License Uol- <br /> , �} one i <br /> TYPE OF WORK (Check): NEW WELL"/_7 DEEPEN %/ RECONDITION / f DESTRUCTION /7 - <br /> PUMP INSTALLATION _131 PUMP REPAIR /PUMP REPLACEMENT /? <br /> Other 1_7 <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 <br /> - <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 /> IrrigationGravel 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 H.P. <br /> PUMPREPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State`Work Done <br /> � F <br /> DESTRUCTION 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 ofthe well, and notify them before,.put.ting.the-well in use. The above <br /> information is -true to the best of my.knowled aand'=bel e 'f, TI WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION;. <br /> SIGNED TITLE <br /> DRAW;PLOTrPLAN ONA-REVERSE SIDE) <br /> FOR'DEPARTMENT USE_ONLY <br />. PHASE I ryr �3"s <br /> fk,1 .-..,, i, = <br /> `APPLICATION.ACCEPTED BY .� �-°,�.���-��' DATE "Z <br /> ADDITIONAL COMMMS: <br /> PHASE II GROUT INSPECTION PHASVI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE =e- <br /> E H 1426 Rev. 1-74�' ,. ' 1 f.77 - 2K <br />