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+- r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 Date Issued Z/___ <br /> (Complete In Triplicate) <br /> Application is hereby made• t6ithe Sart 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 andJthe- Rules and Regulations of the San Joaquin Local Health District. <br /> i' <br /> JOB ADDRESS/LOCATION (dJ CENSUS TRACT <br /> �°- <br /> Owner's' Name y � Phone • <br /> Address _ City <br /> contractor's Name �, License ltl� 237.3 Phone 3 <br /> TYPE OF WORK (Check): NEW WELL;-/? DEEPEN '/7 RECONDITION /-7 DESTRUCTION (_7 <br /> PUMP INSTALLATION`/ / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other F7 yl, <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-11 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia. of Well Casing'. <br /> Dome`sic/pub3�e Driven 1 �' - x-Gauge of Casing <br /> Irrigation .� Gravel -Pack Depth of Grout Seal <br /> Cathodic Protection Rotary , Type of Grout \y <br /> Dis`p.osal Other :; Other Information V <br /> Geophysical Surface Seal Installed B . <br /> PUMP INSTALLATION: Contractor : + <br /> Type of Pump ��. ; H.P. <br /> / <br /> PUMP REPLACEMENT: , . State Work Donep <br /> PUMP 'REPAIR: ti 5 <br /> . /./ S-tate Work Done � <br /> DESTRUCTION OF WELL: Well DiameterApp <br /> # proximate Depth � <br /> Describe Material and Procedure <br /> 4 . . <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 "coo.struction. Within FIFTEEN DAYS <br /> after completion of my work ,an--a.�new mall; I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT._of-th.6 well and- not. y-them before-putting-the-well:-in-:use.... .The- above <br /> infortn�ation is true p.9 the-best of- my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING A AL I CTION. k <br /> SIGNED <br /> TITLE7x44--%, <br /> DRAW.MPLOT PLAN ON REVERSE :SIDE <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS_PECTIO PHAS-9 II ,FINAL INSPECTION <br /> INSPECTION BY DATE :INSPECTION BY _ DATE .' •. '`a <br /> i' <br /> E H 1426 Rev. 1-74 !./rye ora <br />