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Lava Ino SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;gF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 jfl� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <br /> (Complete In Triplicate) <br /> Application is 1iereby 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 Aer-ocr 2� Prj s674, �� a �. CENSUS TRACT Cel- O ed-zZ- <br /> Owner's Name Phone , <br /> Address /n RAOCity <br /> Contractor's Name , License # / y�Phone V <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /./ PUMP REPAIR/ PUMP REPLACEMENT /_7 I <br /> Other <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 OF WELL CONSTRUCTION SPECIFICATIONS a . <br /> Industrial Cable Tool Dia. of Well 'Excavation ! . <br /> I� J Domestic/private Drilled Dia, of Well Casing io <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> f <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: � <br /> - 1 <br /> PUMP INSTALLATION: Contractor � <br /> Type .of Pump `77, K 2 .- H.P. t <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 I hereby -agree to comply with all laws- and regulations of the San Joaquin Local Health District <br /> and the State of California pertaihn'g to or regulating well '4onstruction. 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--mynd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL SPjj" <br /> SIGNED ®/s wTITLEAN ON . RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />` APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I F'IN,AL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 4/75 2MQ:�' <br />