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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. 617FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued _J <br /> (Complete <br /> Application is hereby made to the SanJoaquinr <br /> Local Health District for a r permit it to to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Jpaquir <br /> County Ordi:nance 'No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION Cft�6 A G /N 4 7'/ CENSUS TRACT <br /> Owner's Name G C i°7 So!�L, e'dh/ 178P.71SA Phone <br /> Address 1Dj7irfil+N c-h_ CAMP ' Cit <br /> y1=/?t/ . e-,4aeye4c�� <br /> Contractor's Name S` (� <br /> C _ License # / Phone Z--.—Z zl., <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN / RECONDITION // DESTRUCTION /_7PUMPINSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /N <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I I � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -4)Domestic/private <br /> Industrial . Cable Tool Dia., of Well Excavation f� <br /> Drilled <br /> Domestic/public Dia. of Well Casing <br /> Driven Gauge. of Casing <br /> Irrigation . I Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> -- Other Other Information ' ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> r <br /> PUMP REPLACEMENT: State -Work Done <br /> PUMP `tEPAIR: / / State Work Done s <br /> .DENTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure — ---- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 /> 14ELL 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. <br /> SIGNED 00 0 <br /> J TLE <br /> (DRAWLOT PL ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> P ; { <br /> APPLICATION ACCEPTED -BY DATE <br /> ADDITIONAL COMr!ENTS: l -24X-4 <br /> � ! oc � /!er �r wrrf /1a s a c <br /> PHASE II GROUT INS CTION PHASE III/FI AL INSPECTION <br /> INSPECTION BY DATE `INSPECTION BY - DATE <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H. 1426 <br />