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V <br /> SAN .TOAQUIN LOCAL HEALTH DISTRICT <br /> F ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S—C/J f <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued /�-/7- ;:f- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 11ealth 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 ADDRESSCPfpN -340F e III ' <br /> CENSUS TRACT <br /> Owner t s NamePh <br /> e <br /> oneIsm <br /> Address /tom <br /> Citp " ! <br /> t <br /> Contractor's Name License # Phone� � <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN 17 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION LV PUMP REPAIR -/_7 PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT 'OTHER (A) <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL L,, <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 a Gau of Casing <br /> 8 <br /> Irrigation Gravel Pack Depth of Grout Seal j <br /> Cathodic Protect_ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br />`PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump ,s H.P. <br /> PUMP-eREPLACEMENT: <br /> / / State Work Done ,M.�.. <br /> PUMP '.REPAIR: State Work Done <br /> 4- <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, Twill 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 CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED LE09 <br /> ( PLOT PLg ON REVERSE SIDS <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IIF AL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E,. H 1426 Rev. 1--74 __ - _ - h/75 2M <br />