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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•"OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / <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 S� n ,s+ I- IV,j4A9-!!Z CENSUS TRACT <br /> Owner's Name sS+td& sr '4- 7 ' .z,1 (�A /s .�• Phone <br /> Address e9 O Al A /h ;,OR 4� City (� <br /> Contractor's Name License / honer <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR J -PUMP REPLACEMENT 17 <br /> Other /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 /> 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 "f <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> X <br /> PUMP REPLACEMENT: / / State Work Done 4� <br /> PUMP :REPAIR: & State Work Done <br /> PEES,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 thewell in use.. The above <br /> information is true to the best of my know edge aff elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL INS N. <br /> SIGNED TLE /i•�' <br /> PLOT LAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 5 /7 7�f - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />