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SAN JOAQUIN LOCAL HEALTH DISTRICT / I <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. lu�� <br /> P 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 /,2 <br /> (Complete In Triplicate) <br /> Application isere made to the San Joaquin Local Health District for a permit to construct <br /> and/or install t 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 CENSUS TRACT <br /> Owner's Name S Phone ,T-8 J ; <br /> i <br /> Address City . - <br /> Contractor's Name � License 4l,�y�1 Phone <br /> t� <br /> TYPE OF WORK (Check) : NEW WELT, / DEEPEN /_/ RECONDITION /_/ -DESTRUCTION /-7- <br /> PUMP INS AL ATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY,,"?] � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN6WW '&VATS DOMESTIC WELL-?&L'ILPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . ' <br /> Industrial Cable Tool Dia. of Well Excavation /2 �l r <br /> Domestic/private Drilled Dia. of Well Casing 42 ,11 L'�} <br /> Domestic/public Driven Gauge of Casing 1 <br /> g g 1..4 <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 /> • .41 Y�L <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT / / State Work Done <br /> i <br /> PUMP ,.REPAIR: / / State Work Dane <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 and notify them before putting the wellin use. The above <br /> information is true to theb t m wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG A FIN PE N. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY _ ,9 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BYATE <br /> E H 1.426 Rev. 1-74 1117 _ <br />