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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPSrOFFICE 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 j,� z__—TS� <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 /> JOB ADDRESS/LOCATION.. C� G[//i�'` CENSUS TRACT <br /> Phone <br /> Owner P s Name I:.� i � 3Z <br /> City <br /> Address <br /> Contractor's Name .2 �� � �.4tc'� License # Phone License -- <br /> TYPE OR WORK (Check): NEW WELL /_7 DEEPEN ' RECONDITION /? DESTRUCTION �"T i <br /> PUMP INSTALLATION /� REPAIR /� PUMP REPLACEMENT <br /> Other <br /> it DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY oD <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , q� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL,— <br /> ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION?-PECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation r <br /> Domestic/private Drilled Dia..1of. Well Casing <br /> mastic/public 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: J <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type sof Pump <br /> PUMP REPLACEMENT: /_ State Work Done r Al - <br /> # PUMP'`.REPAIR: /% State Work Done <br /> ES-TRUCTION OF WELL: Well'Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the .San Health District <br /> Joaquin Local <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 t well and notify them before putting.them.well in.use.. The above <br /> r information is true to best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUMa FINAL INSPECTION, <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I � DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II FINAL INSPECTION <br /> PHASE II GROUT INSPECTION ri,�TE <br /> INSPECTION BY DATE INSPECTION BY �'9' "' <br /> 't L H 1426 Rev. 1-74 ' 1-74 2M <br />