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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0g(OFFICE USE: 1601-E. Hazelton Ave. , Stockton, Calif. E <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 he--Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT-A IV <br /> 4 S_rAAl Ed <br /> Owner's Name A Phone <br /> r <br /> Address �n i�a-- � City <- <br /> Contractor's Name ,� License #/G 2373 Phonel <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION. / / 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 LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLY: - 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 '" "`� - _-_ Gzavel'Pack— Depth of Grout Seal <br /> Cathodic Protection `—­, . Rotary Type of ,Grout <br /> Disposal j Other Other Information <br /> Geophysical Surface Seal Installed BX:, <br /> PUMP INSTALLATION: Contractor l 'l <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: i-7 State Work- Done <br /> PUMP REPAIR: // State Work Done <br /> PES•TRUCTION 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 regulatingrwell construction. Within FIFTEEN DAYS <br /> Y <br /> after completion of my work on a new well, I will furnish the Sax: Joaquin Local Health District a <br /> WELL';DRfLLERS 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 FORA GROUT INSPECTION <br /> PRIOR TO GROU NG AND NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DtPARTNENTj4E ONLY <br /> PHASE I f ry� <br /> APPLICATION ACCEPTED BY DATE �/ �1 <br /> i, .ADDITIONAL SONMENTS: <br /> PHASE II <br /> .QRMT INSPEC YON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE IN ECTTON BY DATE R�2 <br /> 4 - <br /> 3 E H 1426 Rev. 1-74 1-74 2M <br />