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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N07-7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is here y 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 Jo4quin„ <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g S �� /�/4/ , *-PNSUS TRACT <br /> Owner's Name 0'— hone �- <br /> G <br /> E <br /> Address City <br /> k <br /> E Contractor's Name License # Phone-/4s—/3 57 <br /> f <br />' TYPE OF, WORK (Check) : NEW WELL`- / DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES/(' FIT PRIVY <br /> 4 <br /> e <br /> SEWAGE,DISPOSAL FIELD 4CESSPOOL/SEEPAGE PIT OTHER <br />+ PROPERTY LINE..- PRIVATE DO STIC WELL PUBLIC DOMESTIC WELL <br />' INTENDED USE TYPE OF WELL ��,,//�(jC� CONSTRUCTION SPECIFIC TIONS <br /> Industrial Cable',-,Tool 1 VDia. of Well Excavation <br /> Domestic/private Dr 11'ed � � Dia. of Well Casing <br /> Domesx c./_pub � <br /> Uc Dr•iuen: a t F - ,—Gaugeof,Casing � <br /> IrrigaCion t ,�. <: _ Grave`lPack� Depth�of {Grout Seal <br /> Cathodic-_P-x_o.tection � -Rotary Type of (G:fout �� <br /> Disposal Other ' Other Information <br /> Geophysical Surface Seal Installed By: „/ ,�/ <br /> 4PUMP INSTALLATION: Contractor �� <br /> Type of Pump H.P. <br /> PUMP REPL-ACEMENT: / j;, . State Work'Done <br /> PUMP ,REPAIR: / j State Work Do <br /> ,DES-TRUCTION E L: Well Diameter : 1 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 Siate of California pertaining to or regulating•weil "cons'truction. 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 t uevto the best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO RO N D A FIINSPECTION. <br /> t SIGNEDTITLE <br /> ! (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS: <br /> I PH49W qnkf SPECTIO P SV II/FI14AL INSPEC oN <br /> :INSPECTIC& BY VATE INSPECTION BY E <br /> ,H 1426 Rev. 1-74 fi !�/ 2 V ''i 7 _. % .2Mi <br /> z �. _ <br />