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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone : (209) ' 466-6781 <br /> EV APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7_,10111j0 <br /> f V` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S-7 <br /> (Complete In Triplicate) ; <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> herein described. This application is made in compliance with San Joaquin <br /> and/or install the workl� <br />} County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION � (� (����"� _ � CENSUS TRACT <br /> Owner's Name Z6 f") Phone <br /> Address ��m� q� City <br /> Contractor's Name J License # Phone d <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR ',V PUMP REPLACEMENT /-J <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Ln <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 , <br /> Industrial Cable Tool Dia, of Well Excavation N <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven- Gauge of Casing <br /> Irrigation- Gravel Pack- _r. Depth of Grout Seal <br /> Cathodic Protection Rotary .hype of Grout <br /> I Disposal i Other Other information <br /> Geophysical Surface Seal Installed By: <br />! PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />! PUMP REPLACEMENT: 477 State Work Done <br /> 1M <br />' PUMP .REPAIR: Sta-te Work DoneNz <br /> r,DESTRUCTION OF WELL: Well Diameter t 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 /> SWELL DRILLERS REPORT ofjlthe well and notify them before putting the wellin use. Tile above <br />' information is true to t1he best of my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GROU I G AND A FI - L INSP CTT N. <br /> SIGNED !Ir' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY ; DATE 1 <br /> ADDITIONAL COMMENTS: E <br /> PHASE GROUT nSPECTION PHA-SE III/FINAL INSPEC IO <br /> INSPECTION BY ;j DATE INSPECTION BY DATE rJ <br /> ! E H 1426 Rev. 1-74� :. --. ��?T ___ <br />