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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01 OFTICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone: (209) 466-6781 7 7_ 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 52Z___72 <br /> (Complete In Triplicate) <br /> Application is Aereby 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. j,862_-an4 tie Rules and Regulati ns of the San Joaquin Local Health District. <br /> 171A T_ <br /> JOB ADDRESS/LOCATIONjTRACT <br /> - )t� <br /> 'e �` <br /> Y i <br /> Owner's Name Phone - <br /> Address c. ' <br /> �J City <br /> Contractor's Name ' 02 0C A License # 2S8. Phone � <br /> _ i <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK> U SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD J�0 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 e) <br /> --L--Domestic/private Drilled Dia, of Well Casing s <br /> Domestic/public Driven Gauge of Casings <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> -Disposal Type of Grout <br /> Other Other Information <br /> Geophysical Surface Seal Installed By: P}AkiA t <br /> PUMP INSTALLATION: Contractor ��< en ILIL.4 <br /> Type of Pump <br /> H.P. � r� <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 thewell 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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> PHASE I FOR EPARTMENT USE ONLY 7 <br /> APPLICATION ACCEPTED BY DATE '� <br /> ADDITIONAL COMMENTS; 17 <br /> PHASE II GROUT INSPECT N <br /> INSPECTION BY ` , ,� PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY <br /> =� DATE <br /> E H 1426 Rev. 1-74 . 1 /77 1W <br />