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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S�4P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued� - <br /> lq0-Zo /1j , (Complete In Triplicate) Ur 0,5-- 2�t o --r k <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 in compliance with San Joaquin <br /> Count Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB��S —�� S ` //J <br /> /LOCATION f /Ove L� _ G�/«G CENSUS TRACT <br /> Owner's Name d 0 l O Phone <br /> Address <br /> City <br /> Contractor's Name <br /> S S License �Phone�✓/732/eD <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/7RECONDITION %f DESTRUCTION f7 1 <br /> PUMP INS CATION J / PUMP REPAIR/_7PUMP REPLACEMENT 1-7 <br /> Other / J 7�� . <br /> z <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t' <br /> SEWAGE DISPOSAL FIELD ~"` CESSPOOL/SEgAGE PIT . OTHER �— <br /> PROPERTY LINBe��PRIVATE DOMESTIC WELL:[�?�qPUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j Industrial Cable Tool - Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ,ter" <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 <br /> Type ofPump H.P. •- <br /> PUMP REPLACEMENT: . / / State Work.,Done <br /> PUMP ,REPAIR: J J State 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 <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-bestof my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED <br /> PL T PL ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY r. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' b <br /> ADDITIONAL COMMENTS: <br /> P OUT INSPECTIO PHASE _Ii INSPECTION <br /> INSPECTION B `DATE "� IN PECTION BYE DATE <br /> E H 1426 Rev. 1-74 hf75 2M <br />