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7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '0) OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7?_/O(, /0 <br /> THISiiPERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued j] <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 hereinidescribed. 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 11ACENSUS TRACT -J <br /> Owner's Name ', I 1L . ,.,_. .---,_--- -•--- Phone <br /> Address 19 city ' J �Q <br /> Contractor's Name •r[J 1� J Z/ �Q License # /Y one <br /> i� <br /> _ _ E <br /> TYPE, OF WORK (Check) : NEW WELL '/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES �r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYSLINE - PRIVATE DOMESTIC�WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia-' of Well Excavation ] <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gaug of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout i <br /> I Disposal Other Other Information <br /> ' Geophysical Surface Seal Installed By { <br /> PUMP INSTALLATION: Cont.rac1tor 1 <br /> T . -TYpe'-of Pump _--H.P. \I <br /> PUMP REPLACEMENT ( State Work Done 1 p <br /> PUMP '.REPAIR: / / State Work Done ' ! <br /> 6ES•TRU_CTION OF WELL: Well Diameter �Approximate Depth <br /> Describe Material and Procedure R <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"�:eonsfruction. ''Within FIFTEEN DAYS <br /> after Completion of my work on a new well, I will furnish the Sari Joaquin -Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in ,u' se. The above <br /> information true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AN A AINAL,I SPE CTJON. I <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> # FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT TNSPECTION PHASE III/FINAL INSPECTI N- <br /> INSPECTION BYDATE INSPECTION BY i DATE <br /> E H 1426 Rev. 1-74 1177 _ 2M <br />