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�9)trSAN JOAQUIN LOCAL HEALTH DISTRICT v <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. 73/7.�/l.•J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> 761969� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Zjp- <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 /> / r <br /> JOB ADDRESSCENSUS TRACT <br /> �r Phone <br /> Owner's Name ?,117 <br /> Address City <br /> Contractor's Name -.Aa v w s icense Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/? RECONDITION /-7 DESTRUCTION fT <br /> PUMP INST LLATION / PUMP REPAIR-/-7—PUMP REPLACEMENT f7 <br /> Other El- <br /> DISTANCE TO NEAREST: SEPTIC TANK 4A9 SEWER LINES PIT PRIVY °^ <br /> SEWAGE DISPO IELD �(t C SPOOL/SEEPAGE. PIT�- OTHER \j� <br /> PROPERTY LINE/0 RIVATE DOMESTIC WELL'�fi'PUBLIC DOMESTIC WELL =E- <br /> INTENDED <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> XDomestic/private Y Drilled Dia. of Well Casing <br /> Domestic/public r T� 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: A4a I�1�{ <br /> PUMP INSTALLATION: Contractor 1' <br /> i .mss <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter DPitfi EK& AF.-,SPG NSI RIQ 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 /> 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 GROUTING AND A FINAL INSPECTIO <br /> SIGNED E <br /> PLO P N REVERSE SIDE <br /> R DE TMENT USE ONLY <br /> PHASE I <br /> AP�PI.ICATION ACCEPT Y DATE �U 'r� <br /> ADDITIONAL COMMENTS: <br /> P E TI ROUT INSPECTION PHASO jII/pjn&L INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />