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V" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />€ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S -sl//w <br /> THIS PERMIT EXP' <br /> IRES I YEAR FROM DATE ISSUED , Date Issued q�jr_Z <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 acid the Rules and. Regulations of the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION r <br /> CENSUS TRACT <br /> Owner's Name jpPI / Phone <br /> Address . /N. Cit �d <br /> y <br /> Contractor's Name �1;0 EA_ /l' 1 !, 1F 6 t11 A l'Q License.# (02 Phone 5�'z <br /> o � <br /> TYPE OF WORK (Check): NEW WELL 4g DEEPEN '/_7 RECONDITION Jf DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR 1_7 PUMP REPLACEMENT /7 <br /> Other ] / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC- DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation Vi <br /> ,Domestic/private Drilled Dia. of Well Casing <br /> '�Aomestic/public. . - = Driven Gauge of Casing <br /> ~ Irrigation : Gravel Pack Depth of Grout Seams <br /> Cathodic Pro,tectio�' Rotary Type of Grout p <br /> Disposal All 72 <br /> Other• Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ <br /> ..• <br /> Type .of Pump . H.P. <br /> i <br /> PUMP REPLACEMENT: - <br /> f / / State Work Done <br /> PUMP '.REPAIR: /_ / State Work Done ` <br /> DES•°TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <br /> Tom. <br /> I hereby agree to"comply with all laws arid-regulatidxis' of the San Joaquin Local Health District i <br /> and the'State of Calif ornia..per taining 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well. in.use.... The above <br /> information is true to the-beet-of. my. knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION ! <br /> PRIOR TO UTING <br /> SIGNED A,FZNAL 'INSPECTION. <br /> TITLE <br /> DRAW PLOT PLAN ON REVERS$ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 . .. <br /> APPLICATION ACCEPTED BYDATE... <br /> ADDITIONAL COMMENTS i ' -:I L Z <br /> - �.. <br /> PHASE II GR INSPECTI N / PHASE 13;Z/FINAL INSPECTION <br /> INSPECTION BY DATE Q 3 INSPECTION BY C' DATR/& f1-7S <br /> EH1426 <br /> Rev74 <br />