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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf�.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 <br /> Date Issued <br /> Application is hereby made to the San (Joaquin Local rHealthtDistrict for a permit3to -IX5 t <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 L cal Health District <br /> �gt�0 <br /> JOB ADDRESS/LOCATION # , <br /> C SUS CT <br /> Owner's Name l b <br /> Phone Ztf 3S� <br /> Address <br /> City c <br /> Contractor's Name <br /> License # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /—/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other /% /I -")'UMP REPLACEMENT /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> THER <br /> PROPERTY LINA L PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFiCATIjO�S <br /> Well Excavation <br /> Industrial Cable Tool Dia, of r- <br /> Domestic/private Drilled Dia, of Well Casing � <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Ef <br /> Other Other Information <br /> Geophysical - - <br /> Surface Seal Installed B c,� �- <br /> PUMP INSTALLATION: Contractor + <br /> Type of Pump µ, <br /> H.P. i <br /> PUMP REPLACEMENT: �- - <br /> State Work Done i <br /> PUMP .REPAIR: '"►- <br /> State Work Done DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and ,Procedure Approximate Depth <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 DAS i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health DistriTt 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 />'R10R TO G ING D A F L INSPECTION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br />?HASE I FO D TMENT SE ONLY <br /> LPP�C ION ACCEPTED BY ' <br /> LDDITIONAL COMMENTS: DATE -j=3 2 y <br /> PHASE I1 GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY ) f DATE 7 INSPECTION BY <br /> DATE � <br /> E H 1426 Rev. 1-74 1177 9M I <br />