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7/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J- xj" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &_ao 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �20 4!2p /I/I%e „ S�-e_ CENSUS TRACT <br /> Owner's Name r-G, �: c lois Phone <br /> Address a //Q p 2 S ��r f`o f'f e _ City <br /> Contractor's Name ft-.Ac,� C�� License # PhoueSO-3YS6 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 <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 /()t S dorri.,f_ J¢ 2 k I: a.tiC, P Cn . <br /> Type of Pump 'T k-r 6h..,e— H.P. 7 v <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <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 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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 2 DATE Zf <br /> ADDITIONAL COMMENTS: <br /> PHASE. TI GROUT INSPECTION PHA4g,IIt/FIDIAL INSPECTJON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i <br /> 1177, 2M <br /> IT <br /> E H 1426 Rev. 1-74 <br />