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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, t <br /> Is° Telephone: (209) 466-678 . , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-7 <br /> !iUa �77 <br /> ! THIS PERMIT EXPIRES 1 YEAR FROM' <br /> DATE ISSUED " Date Issued <br /> (Complete In Triplicate) - <br /> Applicat on is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or tall the work1herein described. This application is .made in compliance with San Joaquin <br /> County finance No. 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 06 3 <br /> JOB ADD C", TRACT <br /> Owner's Name i Phone Z7 2,X2-- <br /> I , <br /> Address Q 404 Z2�AZ,ii City _ <br /> Contractor's Name - License Phoneg <br /> I'I TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> Ih � <br /> DISTANCE TO NEAREST: SEPTIC TANK -Md SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL'- <br /> INTENDED <br /> ELL`INTENDED USE <br /> Ir TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation li. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection YRotary Type of; Grout �p� AY0 <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: , Contractor <br /> S <br /> Type of Pump 1,41 r W H.P. �( <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: �} <br /> State Work Done <br /> r f. <br /> iDES'TRUCTION OF WELL: Well DiameternApproximate Depth <br /> Describe Material and Procedure y <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!llthe 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 /> IPRIOR TO GROUPING AND MiFINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I4 <br /> I� i <br /> APPLICATION ACCEPTED BY:��. DATE Ia - <br /> ADDITIONAL COMMENTS: <br /> k PHA I GR UT I SPECTIOY PHASII/FIEAL INSPECTION <br /> INSPECTION BY DATE /dl INSPECTION BY DATE -� <br /> ! o/77 _ <br />� E H 1426 Rev. 2M�•r1-74 U ��'�`� , <br />