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Cdr_ �lm� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR :FROM DATE ISSUED Date Issued y"X-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 iTi 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 V6 /4j CENSUS TRACT <br /> Owner's Name Phone �1 <br /> Address O96(1 City <br /> Contractor's Name License # Cy3 714-­Phone 7G7i� <br /> y <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / I DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR �/ PUMP REPLACEMENT /^77 <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 <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 �c J <br /> Type of Pump H.P. �- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done �y�rty•y ,�Bj✓ Q� Q /�yfa --.- <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 k wedge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING D A FIN ECT <br /> SIGNED ,,r 'TITLE <br /> Zi (DW P OT7 PLAN ON RE.-VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PBA,5EI I/ INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M., <br /> E H 1426 Rev. - l-74 <br /> of 77 _ <br />