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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 .67Z5- <br /> THIS <br /> ZTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1662 and the Rulee and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ZZ 7 �' Q�nl CENSUS TRACT <br /> Owner's. Name W S 4 Phone _(� 3l- 4Yg1 <br /> Address rk <br /> City S odc- 7�oh <br /> Contractor's NameG'L ��/f �y� �. �/=� `� G <br /> e� License # ��(lZ Phone <br /> TYPE OF WORK (Check): NEW WELL"_& DEEPEN /7 RECONDITION /7 DESTRUCTION f7PUMP INSTALLATION / / PUMP REPAIR '/-7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE 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 /> dustrial .__.� Cable Tool Dia. of Well Excavation /0 <br /> Domestic/private Drilled Dia, of Well Casing eg <br /> ININ <br /> Domestic/public Driven Gauge of Casing a <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done V <br /> PUMP '.REPAIR: / / State Work Done <br />)ES-TRUCTION 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 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 />?ELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.... The above <br /> Cnformation is true to- the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR G OUTING D A INSPECTION. <br />)IGN TITLE QW141/7" _ <br /> (DRAW PLOT PLAN ON REVERSE SID - <br />'RASE I FOR DEPARTMENT USE ONLY <br /> 1PPLICATI0N ACCEPTED BY DATE ' <br />►DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FIN PE <br /> INSCT <br /> INSPECTION BY D TE INSPECTION BYDATE l <br /> Pr�L L <br /> E H 1426 Rev. 1-74 ...� L/7q 9M <br />