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ae SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,:�FICFUUSE_-__j 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedL_Z,JS <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 ADDRESS/LOCATION / 7317 S. S F v ; F� CENSUS TRACT <br /> Owner's Name j } ) A rx, l ) 1 .� . <br /> �( Phone <br /> Address /�� <br /> City rSr 41_4- <br /> Contractor's Name J License lta7 Phone <br /> TYPE OF WORK (Check) : NEW WELL /-J DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT � <br /> Other / / A <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 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 H.P. p / <br /> PUMP REPLACEMENT: / State Work Done i `t •�. r ad <br /> PUMP .REPAIR: /_7 State Work Done <br /> ,PESTRUCTION 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 and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL C L FRA GROUT INSPECTION <br /> PRIOR TO GROU NG MD AOINALINSPECTION. <br /> SIGNED e TIT�.Ei� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE AIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY o j:- z- DATE `-/ <br /> E H 1426 Rev. 1-74 1-74 2M <br />