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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0r, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : <br /> Tele hone <br /> . P (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7d- �1a-7 <br /> ` THIS PERMIT -EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 instal] the work herein described. This application is made in compliance with San. Joaquin <br /> County Ordinance No. 1862 and t e Rules and R ulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ns � � 0 5� <br /> "_ aZ T II [90f <br /> TS <br /> v RACT <br /> i Owner's Name <br /> Phone , <br /> Address s r <br /> a 'City <br /> Contractor's Name12 42 `sz License &2 phone <br /> TYPE OF WORK (Check) :_NEW X9LL_/' [ DEEPEN W- _ <br /> -- a _ / /�.RECONDITION_/_/-._,DESTRUCTION/ - — <br /> PUMMPerINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ' <br /> OthDISTANCE TO NEAREST: SEP . <br /> TIC TANK SEWER LINES PTT PRIVY <br /> .. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER L <br /> PROPERTY kLINE -'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �� <br /> Indixstrial t G .;Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled — <br /> Dia. of Well Casing, .. Q . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout S� <br /> Disposal Other Other Information <br /> Geophysical — -,- - . <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' <br /> H.P. , <br /> PUMP REPLACEMENT: S t }' <br /> / ate Work Done <br /> PUMP .REPAIR: '/ / State Work Done l <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APPrflximate Depth , <br /> 4t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District F <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. weTl in use. The above <br /> information i5 true to the best of my knowledge and belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUNG AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSES E) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: — <br /> PRASE II GR INSPECT / P II/FI AL INSPECTION T <br /> INSPECTION BY _ _ DATE. INSPECTION B DATE 1 <br /> E H 1426 Rev. • 1-74 0/77 _ 2P F <br />