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.. p ad SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: /,601 <br /> E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 IP 9,;2 Q IV, 6 O h kal/ CENSUS TRACT <br /> Owner's Name S / q yv `Gy l� Aa j v Phone'. - 3Q <br /> Address nCity <br /> Contractor's Name 421,71VS �r"fJ�. �`jc Li <br /> cense Phone <br /> TYPE OF WORK (Check) : NEW WELL /A► DEEPEN -/_7 RECONDITION DESTRUCTION f-7 <br /> PUMP INSTALLATION /p f' PUMP REPAIR -/7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTICWELL : PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> n <br /> =p-- Domestic/private Drilled Dia. of Well Casing '� <br /> .Domes.tic./..puhli,c--=�—Driven-'-- - - °-Gauge of-Casing-=� ..I << _ <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> y Cathodic Protection �� Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : ZaS� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: / / 'State Work Done <br /> DESTRUCTION 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 anew well, I will furnish the San .Joaquin Local Health District � .. <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 OUT INSPECTION <br /> PRIOR TO GROUTING AND A..-)FINAL. IN PECTION. <br /> SiGNED . /J <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . r <br /> APPLICATION ACCEPTED BY C. �� DATE ' � f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY ;7 DATE 77 <br /> E H 1426 Rev. 1-74 <br /> - - - - -It/7-5 2M - _ <br />