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SAN 3QAQUIN LOCAL HEALTH DISTRICT <br /> FC? OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a -�A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit' No. 7,6-6 n <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z L>-J6 <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 Distirict. <br /> JOB ADDRESS/LOCATION ,- CENSUS TRACT . . I <br /> Owner's Name <br /> Phone <br /> (� I <br /> Address -z. oY` q- City ,— <br /> Contractor's <br /> ity .Contractor's Name n 1�t,, License # Phone -j., <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN -/=7 RECONDITION /_7 DESTRUCTION /_7 <br /> ; <br /> PUMPINSTALLATION / / PUMP REPAIR -Lx-7 PUMP REPLACEMENT % f <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing F <br /> Domestic/public Driven Gauge of Casing <br /> -, Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump w r� R.P. 'Yr <br /> C/ <br /> PUMP REPLACEMENT / / State Work Done. <br /> PUMP 'REPAIR: / State Work Done L. <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 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 my..knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN IO <br /> SIGNED TITLEi', ` <br /> W POT- PLAN 0 %RSE SIDS <br /> PHASE I "- <br /> FOR DEPARTMUNT USE ONLY <br /> ��7APPLICATION' ACCEPTED BY0____ DATE -7/1 - 7G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION . ..,., PHOE21LWINAe INSPECTIOR <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rwv_ 7._76 <br />