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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 ��� - 9 <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. <br /> JOB ADDRESS/LOCATION rltD�© w ' CENSUS TRACT D3-ZFO- 8� <br /> Owner's Name 1 e- Phone 1z- <br /> Address <br /> _ aj b!� City <br /> Contractor's Name V <br /> Ali a ir b MAP 140) License ��3s" �l�jPhone. <br /> � _ s <br /> TYPE OF WORK (Check) : NEW WELL /, DEEPEN / / RECONDITION /—/ DESTRUCTION /_7 I <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES JjA '. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Exca�ratibri' <br /> --- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth "of Grout Seal <br /> Cathodic Protection R5 Rotary Type of Grout <br /> Disposal Other Other Information f <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP �REPAIR: / / State Work Done k <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 DAIS <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 GR AND INAL INSPECTION. <br /> SIGNED ! TITLE 10, <br /> (DRAW PLOT PLAN ON REVERSE SID.-, ) <br /> PHASE I <br /> F0,R,_DEPAgTMENT USE ONLY <br /> /APPLICATION ACCEPTED BY /yh�. , DATE X� `� <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECT OW P SE III/FINAL INSPECTI N <br /> INSPECTION'BY DATE B7- INSPECTION BY DATE 7 <br /> IL I— <br /> E H 1426 'Rev. 1-74 11177 2M <br />