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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: �'3 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�7 a Aro <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedF--4/ 7 H <br /> (Complete In Triplicate) 7r <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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( CENSUS TRACT <br /> Owner's Name ,s Phone �� <br /> Address S p city 4 ODI <br /> ',] r _ <br /> Contractor's'Name �` I�(1 'L L License # ��ZFhone �o�-n <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION,/� DESTRUCTION /7 <br /> PUMP IN ALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �y <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE 0 " WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing 70Domestic/public - --Driven - Y 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: _ +� <br /> PUMP INSTALLATION: . ContractorNo <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 /> { <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 compl4tion of my work on a new well, I will furnish the San Joaquin Local Health District a I <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 OUT NG AND A FINA INSPECTION. <br /> SIGNED r- TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �- . ° ; i <br /> DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION '` r' <br /> INSPECTION BY -- - DATE - INSPECTION BY ,/ DATE 12 -Y <br />_- E H'1426 Rev. 1-74 f 77 j=` .'.ZM <br />