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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW,'6FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 4- r V APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7C/_3s3 4d 741,-,ZfA�0 ; <br /> ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 Joaquin <br /> . County Ordinance No. 1862 and the Rules and /Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -/c>—�� CENSUS TRACT <br /> Owner's Name&e PyI'-e 0 e) Phone-76 t6 373 <br /> Address ✓c;,' City <br /> 'Cont etor's-Name z License-#- - Phone <br /> TYPE OF WORK (Check): NEW WELL f DEEPEN •/ j <br /> RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION 136 PUMP REPAIR /-7 PUMP REPLACEMENT /-7 C� <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWS LIME 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 SPECIFIC S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing IeD <br /> s Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of GroutQ / <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor �� <br /> Type of Pump TT"U 7Av H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPiREPAIR: /7 State Work Done <br /> ,IDES 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 /> 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•of my.knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, —/--- - <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I --� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CONMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z' <br />� � E H 1426 Rev. 1-74 1-74 2M <br />