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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE 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 <br /> �ffl (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 /> Count <br /> d nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> J41 ADDRESS/LOCATION Gl/, �,� �_ ENSUS TRACT <br /> Owner's Name Phone �1.2 <br /> Address /` <br /> City <br /> 7 <br /> Contractor's Name License A L37 J Phone3a&Y 1�- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/% RECONDITION /_� DESTRUCTION /-T <br /> PUMP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT /- <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing y <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 H.P. -j <br /> PUMP REPLACEMENT: /" / State Work Done <br /> PUMP .REPAIR: 4101 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of Ay knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROVYIW, .AND NAL INS CTION. <br /> SIGNED TITLE <br /> DRAW PIS'T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECIVI6N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4C511 DATE 1 i -,P-.5 <br /> E H 1426 Rev. 1--74 376 2M <br />