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{ <br /> SAN JOAf�UTN LOCAL HEALTH DISTRICT <br /> FOE OFFIMUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / x/- 72 <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. i <br /> E <br /> JOB ADDRESS/LOCATION -,L CENSUS TRACT <br /> Owner's Name Phone - <br /> Address City <br /> Contractor's Name License ��.. 3�// - PhoneL[ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKad/-(SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD A-,— CESSPOOL/SEEPAGE PIT .rt— OTHER p� <br /> PROPERTY LIN90 PRIVATE DOMESTIC WELI­'76Q '+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 <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 By:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r�- � H.P. /S <br /> PUMP REPLACEMENT: / / State Work Done <br /> -PUMP-.REPAIR:- /7-7/—State Work Done <br />` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and'Procedure <br /> EI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Eand 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 wellin use. The above <br /> information is true to th best ofknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TQ UTING D A F A IN TION. <br /> SIGNED TITLE 1Y LA A <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 1 //FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4DATE <br /> i <br /> ADDITIONAL--,COMMENTS: ��6 � <br /> PHASE II 0 INSPECTION PHASE -II /FINAL INSPECTION <br /> INSPECTION BY DATE .INSPECTION $Y1 ✓ DATE �" S' � <br /> • F u lG7Fi Docs 1-7L. /cr <br />