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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �01E_ 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 x/4 - -7 <br /> (Complete In Triplicate) <br /> implication 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 /> (- ,unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION R CENSUS TRACT <br /> ( ner's Name k.(k_ Phone <br /> Address % C i� _ City <br /> (*.ntraQtor's Name cow ;2 , License # Phone <br /> ;�.PE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION �/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> D STANCE 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 WELL 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 Gravel Pack Depth of Grout Seal n <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> MP INSTALLATION: Contractor „�.- (i L G <br /> Type of Pump z H.P. <br /> MP REPLACEMENT: / / State Work Done <br /> ?UMP REPAIR: / / State Work Done <br /> ).?•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 /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ,fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Mformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> GNED 4 TITLE t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ASE I 1 <br /> „PLICATION ACCEPTED BY ti- DATE <br /> WDITIONAL COMMENTS: <br /> PHASE II GRO NSPECTION PHASE II/F AL,;jNSPECTION <br /> SPECTION BY DATE INSPECTION BY DATE "� <br />