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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E77 <br /> : 1601 E. Haze`Iton Ave. , Stockton., Calif. y Imo" <br /> Telephone : (209) 46-6_¢6781 1 <br /> ` APPLICATION FOR WELI;``CONSTRUCTION OR--PUMP PERMIT Permit No. 7,, `7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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/LOCATIONd2 �--"- CENSUS TRACT f <br /> Owner's Name Phone ; <br /> Address City <br /> Contractor's Name ', <br /> License #,2M-,f Phone�� <br /> ._ - <br /> TYPEf-OF WORK (Check) : NEW WELL '17 DEEPEN /`/ RECONDITION / / DESTRUCTION /_7 ; y <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> i <br /> DISTANCE TO NEAREST.: SEPTIC TANK SEWER LINES PIL PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE RIT OTHER k <br /> PROPERTY LINE - PRIV'ATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation q�_t <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing t- - (^ <br /> _,:f-Irrigation Gravel Pack. Depth of Grout Seal <br /> }Ciithodic Protection Rotary Type of Grout -�-- ; <br /> Disposal` Other Other Information `----- <br /> Geophysical Surface Seal Installed BY: <br />'UMP INSTALLATION: Contractor . y� <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: / / State Work Done `" f <br />'UMP_-.REPAIR: State Work Done <br /> f - . <br /> ESTRUCTTON OF WELL; Well Diameter Approximate Depth_ <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws.,and regulations of the Sats Joaquin Local Health District <br /> nd the State of California pertaininglto'1or regulating well -construction. Within FIFTEEN DAYS <br /> fter completion of my work on a 'new well, I tai:-11 furnish thekSan„ Joaquin- Local Healtl District a <br />'ELL DRILLERS REPORT of the well and notify them before putting the wellin use. The :,above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT,-INSPECTION <br /> RIOR TO GRO NG ANDFIN NSP CT ON. <br /> IGNED TITLE <br /> zz�z (D W PLOT PLAN ON REVERSE SIDE) <br /> RASE IFOR DEPARTMENT USE ONLY_ <br /> . <br /> PPLICATION ACCEPTED BY J� DATE 7 `7 <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE r <br /> E H 1426 Rev. 1-74 `8 7: 2 <br />