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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ;7- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued—,a) 1)/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 tJ1g San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � X; ,. '�-72"1 � CENSUS TRACT <br /> Owner's Name <br /> -`i Phone i <br /> Address �< _ /�: t.� .�._ <� City <br /> Contractor's Name + -/ � - �' •l License _Ai Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION 17 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / J <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 <br /> Type of Pump H.P. - <br /> jl <br /> PUMP REPLACEMENT: f / State Work Done r�-- ' - <br /> PUMP .REPAIR: / / State Work Done <br /> DES•®RUCTION 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 AN D FINAL INSPECTION. <br /> SIGNED �e e�� %r,;,� , a TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FPR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY ATE 6-Z,3_-7-) <br /> 1fR _ � 2M <br /> E H 1426 Rev. 1-74 ,_ ,F— <br />