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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS..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 7 <br /> (Complete In Triplicate) <br /> Application ' shereby made to the San Joaquin Local Health. District for a permit to construct <br /> and/or install the work herein des his cation s made in compliance with San Jflaguin <br /> County Ordinance No. 1862 and' the a 'tons o e San Joaqu n Local Heath District. <br /> JOB ADDRESS/LOCATION ✓ "/ <br /> N?US TRACT <br /> J��Owner's Name _ Phon�'"7 e.6 <br /> Address J ® / ✓ Cit k <br /> y i <br /> Contractor's Name , 410 <br /> License � Phone <br /> �t <br /> i <br /> TIRE F Qac ) NEW WELL/ / DEEPEN' /_/ RECONDITION /_7 DESTRUCTION /_7 a <br /> a ?, � � UMP INSTALLATION / / PUMP REPAIR PUMP RE <br /> PLACEMENT <br /> Cher <br /> n 077 <br /> DISTAN NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> SAN J�1�t��U!N LOCAL SEWAGE <br /> •` ., <br /> LINE - PRIVATE DOMESTIC DELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. ,of Well Excavation <br />�,7" Domestic/private I Drilled Dia. 4of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation '� Gravel Pack Depth of Grout Seal j <br /> Cathodic Protection l Rotary Type ;of Grout <br /> Disposal. i Other Other Information � <br /> Geophysical t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work D <br /> PUMP .REPAIR: /% '-St&te Wor <br /> DESTRUCTION OF WELL: Well Diameter , li Approximate Depth <br /> Describe Material and Procedure �� <br /> I_ hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <br /> and the State of California pertaining to or regulating well ''coiistruction. Within FIFTEEN DAYS <br /> after Completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED'', TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �� ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C - <br /> kPPLICATION ACCEPTED BY DATE ' 2 <br /> kDDITIONAL COMMENTS: <br /> PHASE, II GROUT INSPECTION PHASE III/FINAL INSPECT ON - <br /> CNSPECTION .BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 0--AQ A - 0:-.4s9,m 1/77 2M i <br />