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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE.",.. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ,f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - /S 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //'Z 1--7-7 <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 o the oaquin Local Health District. <br /> JOB ADDRESS/LOCATION / -' �'-!� CENSUS TRACT <br /> Owner's Name -�` Phone �3- �Q� <br /> Address lJ'�' .-�-7? " City <br /> Contractor's Name - License #�.`ZPhone �.=? <br /> TYPE OF WORK (Check) : NEW WELL Ale DEEPEN / / RECONDITION / / DEST UCTION' /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6&tf -i.SEWER LINES <br /> t 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 ____7'_ brilled Dia. of Well Casing \` <br /> Domestic/public Driven Gauge of Casing /!F <br /> /i`'"Irrigationy— Gravel Pack Depth of Grout Seal S?1 <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 /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District l <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 <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 TITLE <br /> < (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASF,4W GROU/T INSPECTION PHASE I I/FIN INSPECTI N <br /> INSPECTION BY Ll DATE INSPECTION BY ATE <br /> i yv` . <br /> E H 1426 Rev. . 1-74 <br />