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Co,wpl6 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> 4PLICATION <br /> Telephone: (209) 466-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued--777 <br /> A <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.- 1 <br /> p <br /> JOB ADDRESS/LOCATION . s� CENSUS TRACT <br /> Owner's Name d , r m 1 Phone <br /> Address ,a ,g City <br /> Contractor's Name License # one ' �63Y W-7ol <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / ,/ RECONDITION /__/ DESTRUCTION. / .. . . , <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � yAPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ;i Cable Tool Dia. of Well Excavation <br /> _ x Domestic/private SII Drilled Dia, of Well Casing <br /> Domestic/public ` Driven Gauge of Casing <br /> Irrigation i Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal M Other Other Information <br /> Geophysical I Surface Seal ,Installed By: <br /> PUMP -INSTALLATION: Contractor <br /> Type of Pump =Cz ol6kgz H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,,REPAIR: /1j / 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 and notify them before putting thewell in use.. The above <br /> information is true to the best of y kno led-geJan. belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRD TING AND .A FTN . --I- PE TI N f <br /> SIGNED - F �r�� ITLE _ /"ts� <br /> ( W PLAN ONSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY' ,-DATE •„Z,S-'] <br /> ADDITIONAL COMMENTS: 1i <br /> PHASE II GROUT INSPECTION P S INAL INSPECTION <br /> INSPECTION BY . i DATE INSPECTION BY DATE <br /> E 'H 1426Rev. 1-74 i 1/77 _ 2M <br />