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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1F08 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.5-l/1�lko <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ll-,7-7S <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 7/ -30 Ax� 1± � 7 eCENSUS TRACT , <br /> Owner's Name -J?u Phone <br /> Address City 2-0 <br /> Contractor's Name ✓twLicense # 1 � 3.-j Phone <br /> "� SIGH <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X� PUMP REPLACEMENT /7 <br /> Other /-7 <br /> _ 0 <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 /> X Irrigation Gravel Pack Depth of Grout Seal EE9 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal In_s,.taalled BY: <br /> PUMP INSTALLATION: Contractor Xt)e,�e',r'� <br /> Type of Pump H.P. — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done `�/10 c /,A h a C} 041 4- <br /> ,SES 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 knowledge a"nd-be ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 9AWTING AND A FINAL INSPECT ON. <br /> SIGNED <br /> °_ Ajw�- 1.0 TLE 2' <br /> (DRA 0 ON REMSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: T <br /> PHASE II GROUT INSPECTION PHASE II FIN,AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> :E H 1426 Rev. 1-741-7 <br /> 4 2M <br />