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FSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 71 <br /> FOE OFSFICE SSE: 1601 E. Hazelton Ave. , Stockton Calif. ' ' <br /> Telephone : (209) " 466-6781 [�J <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7/Vt / <br /> ��yTHIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued �7I (Complete `In Triplicate)Application is h 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 /> County Ordinance No., 1862 and °the Rules and 'Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION-5j <br /> CENSUS TRACT <br /> Owner's Name Al <br /> Phone <br /> Address / <br /> City <br /> Contractor's Name <br /> . -- . - I J License f6 t Phone _�/$� <br /> { , -- i <br /> i <br /> TXPE 4F WORK (Check) : NEW WELL / / � DEEPEN / / RECONDITION`/-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / UMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f _ <br /> �,�" - EWER LINES ----PIT PRIVX f I <br /> SEWAGE DISP SAL MELD -'--CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL 6al PUBLIC DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL ` CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia, of Well Excavation ++ 1 <br /> DomestDomestic/private I Drilled Dia, of Well Casing j <br /> E, <br /> Irrigation <br /> Driven Gauge of Casing <br /> Irrigation k Gravel Pack.1 fv, Depth of Grout Seal <br /> Cathodic Protection `. Rotary Type of Grout <br /> Disposal Other ,Other. ioInformatn +� (� <br /> Geophysical f <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump; H.P. <br /> PUMP REPLACEMENT: . /; / State Work Done' <br /> PUMP .REPAIR: /; /m .State Work Done t <br /> DESTRUCTION OF WELL: Well Diameter ..� <br /> Approximate Depth <br /> Describe Mater 1 and Procedure 1 <br /> I hereby agree to comply with all laws and -re-gulations of-the-San-Joaquin Local Health District <br /> and the Stave of Cal'ifornia`,�pe.rtaining to-,or .regulating well 'construction. Within FIFTEEN DAYS <br /> after completion- of my work on,a new•wel7`,'. will-llthe San Joaquin Local Health District a <br /> WELL DRILLERS kEPORT'-of the well and notify`-th�em`b.efore j,putting.the wellin use. The above <br /> information is true to hebest my knowledge -and belief. I. WI_LL CALL FOR A GROUT INSPECTION <br />?RIOR TI AND F A 4- _ <br /> SIGNED ON. <br /> TITLE Al <br /> {DRAW PLOT'PLAN_ON REVERSE SIDE) <br /> FPR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY_ __ - r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY ruI/M_ T_ DATE INSPECTION BY - <br /> •- ; <br /> E H 1426 <br /> - - <br /> -.s� _ ev. ' 1177 9VI/ <br />