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SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FOP -OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J-6gefo <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 4-j<_ Z <br /> .I (Complete In Triplicate) <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 5 <br /> JOB ADDRESS/LOCATION Y" I S � CENSUS TRACT <br /> Owner's Name Ie's '�� M '461� t. Phone <br /> 1 <br /> Address <br /> AGI 'oe ,0116&�.- --- - - - city <br /> Contractor's Name License 4 ��Phone <br /> { TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP#INSTALLATION / / PUMP REPAIR -./C/ PUMP REPLACEMENT <br /> Other <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 CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installdd .By <br /> PUMP INSTALLATION . Contactor <br /> Q,Type`�of Pump a� i H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: %/ State Work Done +,� ����, <br /> DES-TRUCTION 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 /> l 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 best knowledge—an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO WO TING AND A FTN ECT N <br /> SIGNED TITLE �,� <br /> PL AN ON R. = RSE SIDE) <br /> W <br /> FOR DEPARTMENT` USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G Oi SP TION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE /�j- ,]7 <br /> •' 2ME H 1426 Rev. 1-74 ' 117.7 <br />