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+ � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF'+OFFICE USE: j/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No."7� -"&cd <br /> THIS PERMIT EXPIRES 1 YEAR MPA DATE ISSUED Date Issued <br /> (Complete In Tripli ate) —�' _ 1 X <br /> Application is hereby made to the San Joaquin Local Health District for `permit t o construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County <br /> �Ordinance No. 1862_ and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIION� 11 / :v /}//,� (�„I4g R /U G�N94!RA T <br /> Owner's Name ` l_, G G Phone ep <br /> Andreas :ATE ,�� city <br /> Contractor's Name � _��,.� License # /l— •fig/ Phone <br /> C-S -SG <br /> TYPE OF WORK (Check): NEW WELL��DEEPEN L-7,,RECONDITION /7 DESTRUCTION <br /> -.PUMP INSTALLATION O PUMP REPAIR / /—PUMP REPLACEMENT %T <br /> Either <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation ZA44- <br /> Domestic/private Drilled Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing I <br /> �L_-<trigation Gravel Pack Depth of Groue)Seal f <br /> Cathodic Protection Rotary Type of Gro utl <br /> Disposal , Other the'�rx n. ^ <br /> Geophysical s , Surface Seal ns µ <br /> PUMP INSTALLATION: S <br /> Contractd <br /> Type of P mp H.P. D ? <br /> PUMP REPLACEMENT: / / State Wor one Y <br /> PUMP :REPAIR: <br /> f /? State Work Done <br /> EESIRUCTION OF WELL: Well Diameter Approximate Depth { <br /> Describe Material and Procedure <br /> 41 <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO OU NG AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY J DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY }DATE)1211 <br /> p -� <br /> E H 1426 - Rev. 1-74 f�� '� 7.5 � <br />