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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 7,2- IM 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/��7,' <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 t u e nde u t o t e an Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION -- /�"t ©� - NSUS TRACT <br /> Owner's Name � T - . _ Phone <br /> Address r City ` ' <br /> Contractor's Name [!� r License.& Phone-7 �/ <br /> z <br /> TYPE OF WORK (Check) : NEW WELL/ EEPENRECONDITION /_7 DESTRUCTION /_7 <br /> /_/ <br /> PUMP INSTALLATION fi!P REPAIR / J PUMP REPLACEMENT /7 <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 /J <br /> ,Bamestic/private Drilled Dia. of 1e1 �ICasing <br /> Domestic/public given Gauge of Casing f a <br /> Irrigation - Gravel Pack Depth of Grout Seal �sr[►, <br /> Cathodic Protection L---Rotary Type of Grout � 5 ,��' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PWIP INSTALLATION: Contractor { <br /> Type of Pump H.P. <br /> POMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /, / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth w <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 wellm'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 GRO ING AND A FINAL INSPECT b <br /> SIGNED TITLE <br /> (DRAW .PLOT PLAN ON..REVERSE SIDE) <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ___��Jjcl\01 DATE <br /> ADDITIONAL COMMENTS: <br /> PHA5E. I ROUT INSPECTIOPH_4S�PjXI/jqNAL INSPECTION <br /> INSPECTION BY DATE d / INSPECTION BY DATE � 2 -77 <br /> .7 _ 2M <br /> E H- 1426 Rev. . 1-74 _ - -_ �: <br />