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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> E - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Permit No, 7 <br /> 4 <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application .is hereby made to the San Joaquin Local Health District for a permit to construct <br /> t 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 Sari Joaquin Local Health Districtf. <br /> JOB,ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Az { ryJ' Phone ' <br /> Address City `—i c� <br /> l Contractor's Name License #G Thone ' y 742,C <br /> TYPE OF WORKCheck) : NEW WELL _ <br /> ( / / DEEPEN / / RECONDITION /_/ DESTRUCTION /� ,G <br /> PUMP INSTALLATION / / PUMP REPAIR/jC/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TY " , <br /> PE 0 <br /> F <br /> WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. of Well Excavation <br /> `�c Domestic/private Drilled; Dia. of Well Casing <br /> Domestic/public Driven Gauge of Ca, irig <br /> Irrigation r ' Gravel Pack Depth•-of Grout,Seal_ <br /> Cathodic Protection Rotary ,y Type of Grout <br /> Disposal Other Other Information ^' <br /> Geophysical <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump �. H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> _ r <br /> PUMP REPAIR:----, � /?C/ ._.State_ Work-Done,_ <br /> PES-TRUCTION OF WELL: Well Diameter Approximate Depth . j <br /> Describe Material and Procedure , <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health District <br /> and the State of California pertaining to or regulatink well.'construction. Within FIFTEEN DAYS <br /> after completion of my work ona 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 $ IO <br /> SIGNED ��. TITZErp . <br /> WRAW PLAN 'ON MERSE SIDE) r ' <br /> PHASE I <br /> .5��OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED- By DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GRO SPE TION,_ PHAS III/F INSPECTION <br /> INSPECTION BY DATE INSPECTION BYZE f, DAT <br /> �. <br /> EH 1426 Rev. 1-74 <br />