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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1601 E. Hazelton A:ve. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATIO9 FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> (Complete -In-Triplicate) <br /> Application is hereby made to the Sat: 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 andRegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IL� - CENSUS TRACT <br /> Owner's Name d P.4 16/4E�� Phone 2Z.7 a%� <br /> Address _ L. ,r l � � City ..&a-h-e �^U� <br /> Contractor's Name � _�rS/�1 �n,�//l�l/�3_ License IR1936k Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN'/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK .1___-__� SEWER LINES JVP PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT lob 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 1 '� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 19-25} ' <br /> Cathodic Protection Rotary Type of Grout 5/y)/d'41 <br /> Disposal _ Other Other Information �!U <br /> �� �l1 <br /> Geophysical Surface Seal Installed By: 5:9 <br /> PUMP INSTALLATION: Contractor _ <br /> r9 <br /> Type of Pump T- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: '� L7- +State Work Dane <br /> ZES-TRUCTION 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. 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 INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION / PHASE III FIN INSPECT N <br /> INSPECTION BY DATE d INSPECTION BY DATE <br /> ? E H 1426 Rev. 1-74 1-74 2M <br />