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SAV JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFOFF-ICE USE. i 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z::j <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued _/-5-- <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 ADDRESSILOCATION CENSUS TRACT <br /> Owner's Name p� Phone. E <br /> 4 I <br /> Address City Ly / <br /> } <br /> Contractor's Name A�. License Qj-jW�Phone <br /> E <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / `/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT' PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <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/privatell Drilled Dia. of Well Casing <br /> Domestic/public Driven -- Gauge of Casing <br /> ��Irrigation Gravel Pack ff Depth of Grout Seal <br /> Cathodic Pr.otection Rotary Type of Grout <br /> Disposal <br /> _.. <br /> �- WAOther Other.. ' . ...: :_ >..: .._..:. n ... .. Information <br /> Geophysical . Surface Seal.-Installed By: <br /> PUMP INSTALLATION:; Contractor J. <br /> Type of Pump H.P. �Gd <br /> � _ <br /> j <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /a(/ State Work Done CmLl /,J 14e, sc A_._.. . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> _ P <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 'eonstruction. Within FIFTEEN DAYS. I <br /> after completion of .my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPOk" of the`well and notify them before putting 'the well in use. The above <br /> information is true to the best of my knowled n.d belief. I WILL CALL FOR A GROUT INSPECTION 1 <br /> PRIOR TO .54UTING AND A F F ON } <br /> SIGNED, ITLE <br /> (D L P. AN ON kVWE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , ` <br /> APPLICATION ACCEPTED BY DATE "7` IJ1 7 7 <br /> ADDITIONAL COMMENTS: + <br /> PHASE II G OUT INSPECTION PHASE III INAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY- DATE Z� <br /> , 1177 _ C <br />�_� E H 1426 r,Rev. 1-74 <br />