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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. R1� <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 Date Issued <br /> � 8 (Complete In Triplicate) <br /> Application is Aere de to the San Joaquin q n 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L CENSUS TRACT <br /> Owner's Name Phone <br /> Address City F'Sc"4,16.1 <br /> Contractor's Name 4t6jArgo License Phone - f <br /> 12 <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST; SEPTIC--TAN K SEWER LINES -.-- PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE-a{PRIVATE DOMESTIC WELL --- 'UBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> NY <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing $ J <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 of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / 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 HealthDistrict' <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 96tify them before putting the- well in use. The above <br /> information is true to thb a knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG D A FV IN ION. <br /> SIGNED TITLE17 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY % DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHAS AI GR UT INSPECTION PHAS IFIN4V INSPECTION <br /> INSPECTION BY DATEyj INSPECTION BY p <br /> E H 1426 Rev. 1-74 ; 1 r77 2M <br />