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SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 3i <br /> . •, Telephone: {209}' 466-6781 <br /> f� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-7-1-3-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lo ;-711-77 <br /> (Complete In Triplicate) <br /> Application is Aerebyy 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 ADDRESS/LOCATION D 3 3 CENSUS TRACT <br /> Owner's Name ,s Phone <br /> Address Q 3 0 _ �o City "A c"Al <br /> Contractor's NameLicense #Z2& Phone <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP 1 ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKZQAp f SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELL/.,Sia' PUBLIC DOMESTIC WELL 9 <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 /> _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of GroutF-Mx-,� <br /> Disposal Other Other Information <"10-LOM /LOA 1"j, <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: •�` 7` _(, 117 <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 aXT <br /> otify them before putting the..well in use. The above <br /> information is true to th =,Zj <br /> knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR G NG D A F - ON. <br /> SIGNED TITLE <br /> ff (DBAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ,f <br /> APPLICATION ACCEPTED BY DATE p <br /> ADDITIONAL COMMENTS: <br /> PHASE I PE ION PHA$E /FINZINSPECTIOkk <br /> INSPECTION BY E INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 UP 2M <br />