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f <br /> 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 No. 7S= [j 6L�J <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 /> 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 /> JOB ADDRESS/LOCATION AlR at i CENSUS TRACT <br /> Owner Is Name ' ' Phone jdU G <br /> Address _ City . 1 <br /> Contractor's Name <br /> Licensehon <br /> { <br /> F <br /> TYPE OF WORK (Check): NEW WELL ':./ 'DEEPEN -/ / RECONDITION /7DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /% -- <br /> G <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 OFIWELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , two—Cable Tool Dia, of Well Excavation <br /> #+°'tfomestic/private Drilled Dia. of Well Casing ee <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Grout: <br /> Cathodic Protection Rotary Tyle of G <br /> Disposal Other ®they Information <br /> Geophysical- Surface Sea10 <br /> tInst'alled BY:PUMP INSTALLATION: Contractor -11 <br /> Type of Pump H.P.god PUMP REPLACEMENT: / / State Work DonePUMP !REPAIR:_:; /� ,State Work Done - � <br /> E&TRUCTION 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.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 ;EI� AND A FINAL IN PE N. <br /> SIGNED <br /> TITLE f <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY SOP- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTI N <br /> INSPECTION BY = DATE INSPECTION BY DATE4,0 <br /> / <br /> y <br /> E $:1426 Rev. 1=74 1-7L IM <br />