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x SAN JOAQUIN LOCAL HEALTU DISTRICT <br />FO$IrOFFICE USE: 1601 E. Hazelton Ave. ,_Stockton, Calif. <br />Telephone: (209) 46£-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 e- <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued !j-2p-7 <br />Complete In Triplicate) <br />Application is hereby made to the San Joaquin Local Health Distirict 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 th.g-Rules and Regulations of the San Joaquin Local Health District, <br />JOB ADDRESS/LOCATION % F. nu, © CENSUS TRACT z-tlo a <br />Owner'S_Name P Phone <br />Address q' City <br />llI <br />Contractor's Name 5 -L r I License # 2fG j Phone Jr- j/ <br />I <br />TYPE OF WORK (Check): NEW WELL /17r DEEPEN /? RECONDITION /7 DESTRUCTION %j <br />PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT <br />Other /%i <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 ExcavationyL <br />Domestic/private Drilled Dia. of Well Casing <br />E Domestic/public Driven Gauge of Casing <br />Irrigation Z Gravel Pack Depth of Grout Seal <br />Cathodic Protection Rotary Type of Grout <br />Disposal. ' Other Other Information `QV) h4 j 6-tC2 ,Lj <br />Geophysical Surface Seal Installed By: <br />PUMP INSTALLATION: Contractor <br />Type of Pump H.P. <br />PUMP REPLACEMENT: State Work Done <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 FORA GROUT INSPECTION <br />PRIOR TO ROUTING AND FINAI. SPE CT ION. <br />SIGNED <br />J <br />TITLE Q <br />W PLOT PLAN ON gRVERSE SIDE) l <br />F0 nEPARTMEN USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY DATE /Y— <br />ADDITIONAL COMMENTS: <br />I PHASE II GROUT INSPECTION ' PHASE 11I FINAL INSPECTION <br />INSPECTION <br />BYrI <br />DATE INSPECTION BY DATE <br />E H 1426 Rev. 1-74 1-7 4 7M