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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No. 7ZV- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z11- � <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 Ppulations of the San JoaquilV Local Health District. <br /> ---tee ,�C <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NameI If Phone X R- <br /> Address -z -. . city ,!�SC OLOj ..._ . <br /> Contractor-s-Name - License_41a 2- ./p.phone. . <br /> E <br /> TYPE OF WORK (Check): NEW_ k1EL-L /? DEEPEN / PRECONDITION /7—DESTRUCTION /7'" <br /> PUMP INSTALLATION PUMP REPAIR /7 / PUMP REPLACEMENT <br /> t Other El <br /> r <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 ` `Alt CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well Excavation { <br /> Domestic/privateDrilled Dia. jof-Wkl Casing <br /> Domestic/public Driven Gauge�of; Casing <br /> Irrigation ' Gravel Gravel Pack; Depth of Grout Seal <br /> Cathodic Protection Y' Ratairy ' Type of Grout <br /> Disposal "C Otler. , , Other Information <br /> Geophysics] }} Surface Seal Installed By: <br /> PUMP INSTALLATION: { <br /> Contractor <br /> '�.,, � -_ ,tip 1 ��1 .r.�� .tt�.� r'��a �� '� <br /> - TfType of Pump k H.P. 1,I, Pr <br /> PUMP REPLACEMENTS I I State Work Done <br /> PUMP":REPAIR; <br /> k ' <br /> E&TRUCTION OF WELL: Well Diameter f Approximate Depth <br /> Describe Material and Procedure <br /> a <br /> I hereby agree to comply with all laws and regulations of thekSan 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 notifythem before <br /> putting..the. well in use. The above J <br /> information is true to the-beet-of- my-knowledge and belief. I WILI; CALL FOR,A GROUT INSPECTION , <br /> PRIOR TQ GRQ ING AND &FINAL INSPECTION. 7 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I pk <br /> APPLICATION ACCEPTED BY �" DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHAS III¢ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br />} E H 1426 . Rev. 1-74 1-74 2M <br />