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SAN JOAQUIN LOCAL HEALTH DISTRICT !!/ <br /> FOPS-OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 Ir <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 14' <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 62[a CENSUS TRACT <br /> Owner's NameAt 10 &A LjO <br /> Phone 3 3114 <br /> AddressCity <br /> Contractor's Name-AQ i _ _ _ License 4�3y �y Phone 3toCf-, 5' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION-/—/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / 2 <br /> DISTANCE TO NEAREST: SEPTIC TANK I% SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> h <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 r� <br /> - X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /_-) ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection y 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. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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 G OUTING AN A FINAL IIJSPECTION. <br /> SIGNED R174a -Y\ TITLE <br /> .�S <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYxLDATE <br /> ADDITIONAL, COMMENTS: � - - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> 7, -Z�,p <br /> 77 <br /> 7 2ME H 1426 Rev. - I-74 <br /> _ <br />