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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,5---,),d-' <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 /> • I r � <br /> JOB ADDRESS/LOCATION 040.10 �i 2 �� ( jai. , .n ,�1 CENSUS TRACT <br /> Owner's Name (J O / 1 ��� Phone - <br /> Address - -I City <br /> Contractor's Name / �i3 r� C_ n . License U ' Phone .'�' <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALr ION UMP , PAIR / / PUMP REPLACEMENT /7 <br /> CA Other <br /> DISTANCE TO N ST: SEPTIC T K �r/ ' bLWhXrL1ffb6I 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. Excavation / <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: �-),l <br /> C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump M ,� , •; . H.P. <br /> PUMP REPLACEMENT: / / State Work Done r__ <br /> C, <br /> PUMP .REPAIR: / / 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 'k <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 /> ?RIOR TO GROUTING AND A IFTNAT. I "PE N. <br /> SIGNED TITLE rI " <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I AL INSPECTIO <br /> INS CTION BY 6141P DATE92h, SISPECTIONBY DATE <br /> 1426 'Rev. 1-74 ;P' � 5--y ? <br />