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5 <br /> C�m SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OT OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM- DATE ISSUED Date Issued <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San J6aquin Local Health District for a permit to construct <br /> end/or ,install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` A(r1� kJ �� _ / .1a � a CENSUS TRACT <br /> ! Owner's Name Phone <br /> Address '7 'a D A4 9414 0k.) City . CSW <br /> Contractor's Name ,t) License # PhoneC► 17 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR & 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 WELT. PUBLIC DOMESTIC WELL m <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 <br /> Irrigation Gravel Pack Depth of Grout Seal ' Z <br /> Cathodic Protection Rotary Type of Grout fh <br /> Disposal Other Other Information <br /> ' Geophysical Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �"',�.,� H.P. 412 <br /> PUMP REPLACEMENT: / / State-Work Done i <br /> 60 <br /> PUMP REPAIR: State Work Done 000 , ( Adz,& <br /> 2ES-TRUCTION OF WELL: Wells 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..the• well in.use.. The above . <br /> information is true to the-best-of my owled ief. 'I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO G OUTING ANDA FINAL <br /> SIGNED fr.► TLE " <br /> (DW ELM PLAN ON RE RSE SIDE <br /> k-YOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY, ;- _:_ DATES _U 7,5 <br /> ADDITIONAL COMMENTS;: .� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Al DATE <br /> t E H 1426 Rev. 1-74 1-74 2M <br />