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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7C, ,_1_5- /0 <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 an gulations the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t CENSUS TRACT <br /> Owner°s Name L/i(, V4 3 Phone � <br /> Address G City C L7X Xt/ <br /> Contractor's Name L:W, License #9 01V Phone IX, o7 <br /> TYPE OF WORK (Check); NEW WELL -/-7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other /-7 <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 <br /> 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 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 Dane �G-e ZE ,,,�, .,_s 7�!_J �� �,� <br /> w. r <br /> PUMP !REPAIR: - -7 State'Work Done - <br /> ES•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 GROUTANSPECTION <br /> PRIOR TO GROU NG AND A I INSPECTION. � d. . <br /> SIGNED TITLEAm <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Za2zAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: .` <br /> PHASE II GROUT INSPECTION PHA N NSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE <br /> OFr <br /> I� E H 1426 . Rev. 1-74 <br /> 1-74 2M <br />