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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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/,'73 , <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 CENSUS TRACT <br /> Owner's Name Jo Am "Tyafa/z p Phone <br /> Address _ &try _ City <br /> Contractor's Name License Phone <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 101Y.14 SEWER LINES Ifill f-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICWELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i, Cable Tool Dia. of Well Excavation / $let <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /fZ_ <br /> t-, 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: fa12M.MWit. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 TITL . <br /> (DRAW PLOT PLAN-ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY if DATE z��A;Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONkHASE,01/FIN4 INSPECTI N <br /> INSPECTION BY �DATE INSPECTION AT <br /> - <br /> E H 1426 Rev. -I-74 b/77 2M <br />