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SAN JOAQUIN LOCAL HEALTH DISTRICT 7 <br /> FOF_ OFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 i ,! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - �7�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE,'ISSUED Date Issued <br /> kj (Complete In Triplicate.) <br /> Application is hereby made to:kthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein. described. This application isj-made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the�an Joaquin Local Health District. <br /> ' <br /> JOB ADDRESS/LOCATION �� ���1'Jt� CENSUS TRACT <br /> P <br /> Owner's Name —�---' hone �9 Q- <br /> Address a x., � / R city. <br /> Contractor's NameChi <br /> License ��A ��� Phoneme <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION P / DESTRUCTION /- <br /> PUMP INSTALLATION / J PUMP REPAIR / / ; PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- I DOMESTIC WELL ` PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation � . <br /> Domestic/private Drilled Dia, of Weld Casing <br /> Domestic/public l Driven Gauge of Casing 7 <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> CathodiciProtection 1 Rotary Type of Groiut <br /> Disposal A Other Other Information - <br /> Geophysica-1 j Surface Sea:1 Installed:.By: <br /> PUMP INSTALLATION: Contractor awAv ce�� <br /> -- - -`—Typ of Pump -qui H.P. <br /> `'. . <br /> .. .,,,,,,.,�_..��.-�..-,�,..-.r_-..-� �__._- .. _ -;`--.- gipp .�,:.-:,s--- -- •.�e <br /> PUMP REPLACEMENT: A/ State Work Donedu�`6 <br /> PUMP REPAIR: / / Sate Work Done <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 f <br /> after completion of my work on a new well, I will furnish the.I5an 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 GROUT INSPECTION <br /> PRIOR TO G OUTING AND FINAd INSPECTION. <br /> SIGNED ' y ' TITLE C--�U`✓� <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> + FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT IlfSPECTION iPHA YXII/FI AL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - 1-74 <br /> �y n�77 _ M <br />