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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I ' Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR POMP PERMIT Permit .No.7 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date;",1ssued =_2- 2 <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 describe%'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 e k,, 140 t%..0 C CENSUS TRACT <br /> 1 <br /> Owner's NameJ P e✓. Phone Z 7 <br /> t <br /> Address A City _Vfwz:;2� <br /> -.Contractor-'s .Name. . A ' .p., IOU A;1-01 k. 4 . <br /> License l Phone 3fr <br /> TYPE OF WORK (Check) : NEW WELL /Ef DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP ,INSTALLATION / / PUMP REPAIR / •/ PUMP REPLACEMENT <br /> 0 Cher I/ / - <br /> DISTANCE TO NEAREST: SEPTIC #TANKInt¢, SEWER LINES F . PIT PRIVY <br /> SEWAGE �DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER _ <br /> PROPERTY LINE-V PRIVATE DOMESTIC WELL t`� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable :Tool Dia. iof. Well,.Excav_ation /�L « <br /> C - Domestic/private I Drilled Dia. of-Well. Casing <br /> Domestic/public 4 Driven Gauge of Casing <br /> \. Irrigation i Gravel Pack Deprth of Grout Seal �f . ...,. <br /> Cathodic Protection -A j_, Rotary Type of Grout <br /> Disposal. 1 Other Other Information <br /> Geophysical' <br />� �. _ n .. .,_ Surface Seal Installed B � <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 DiameterApproxim ate 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 o`f the well and notify them before puttingthewell 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTI TLE <br />` (DRAW PLOT PLAN ON REVERSE S E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,2-R 71 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 'T <br />