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_;r4 SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE 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 6-�1�7� <br /> i (Complete In Triplicate) ' <br /> Application is -taereby- 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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name � Phone <br /> Address <br /> Contractor's Name / Licensee -;7-7-;,Phone Jd�� <br /> Z <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION % <br /> PUMP INSTALLATION %/I PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 Ilk <br /> Industrial Cable Tool Dia, of Well Excavation N <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 B <br /> PUMP INSTALLATION: Contractor H.P. <br /> ;Type of Pump - <br /> � <br /> REPLACEMENT: . / State Work Don � •PUMP � - <br /> PUMP .REPAIR- "/ / —State Work Done: <br /> 4 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 /> TITLE <br /> SIGNED L� <br /> RAW -PIT FLAN �ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE - <br /> i APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II/FINAL INSPECTION <br /> PHASE II .-GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> i Q>3/76 2M <br /> I <br /> 4 <br /> E H 1426 Rev. 1-7 ' <br /> � . <br />