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�. SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> [_ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 �l �J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .rte/L-77 <br /> F (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 /> r <br /> 'JOB ADDRESS/LOCATION Q &4.a CENSUS TRACT ' <br /> Owner's Name ,-r Phone <br /> Address city Af <br /> Contractor's Name License ff&iffPhone <br /> . i <br /> R <br /> TYPE OF WORK (Check) ; NEW WELL/L DEEPEN /_% RECONDITION /__/ DESTRUCTION /_7AL <br /> PUMP INSTLATION -/ / PUMP REPAIR f / PUMP REPLACEMENT /_7 V <br /> Other /_7 i <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> i 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 /> IndustrialCable Tool Dia., of Well Excavation f�� <br /> Domestic/private Drilled Dia, of Well Casing _ 141 <br /> Domestic/public Driven Gauge ,of Casing /0 <br /> Irrigation Gravel Pack De' <br /> pth�of Grout SealQ ' <br /> Cathodic Protection Rotary Type of Grout Cep .,-, 7-- <br /> Disposal Disposal Other Other-Information ' <br /> Geophysical Surface Seal Installed By: v ,ti., tib_: <br /> PUMP INSTALLATION: Contractor <br /> Type, of Pump H.P. <br /> PUMP REPLACEMENT: / ./'` State 'Work Done y <br /> PUMP .REPAIR: / / State Work Done .� <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth x _ <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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLWD F <br /> DRAW41 T PLAN ON REVERSE S <br /> PHASE I <br /> FOR,DEPARTMENT USE ONLY a <br /> ` <br /> APPLICATION ACCEPTED BY i' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION-BYA --� DATE -�; : INSPECTION BY DATE <br /> E H 1426 Rev. 1-7475 ?P+! > , <br />