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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> 94 <br /> FOA�O ICE USE: 1601 E. Hazelton Ave.', ,Stockton, Calif. <br /> Telephone: (209) 466-6781-,,.,'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT .Permit No.7 — A- /�' <br /> THIS PERMIT EXPIRES l YEAR'FROM,,.DATE ISSUED Date Issued - <br /> (Complete In-;Triplicate) <br /> Application is hereby made tol the San Joaquin .Local';Heaith District for a permit to construct <br /> and/or install the work hereim described. This application is made in compliance with San Joaquin <br /> County-Ordinance No. 1862 arid'the Rules and Regulations.-.of the San Joaquin Local Health .District. <br /> JOB ADDRESS/LOCATION �� 9' r� �' /� CENSUS TRACT <br /> Owner's .Name[?- n ir�a _ kPhone <br /> 'Address City <br /> -Contractor's Name y License # JJ3 �1.,Mone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN -/'7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /e7 PUMP REPLACEMENT f <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 /> Industrial, t Cable Tool Dia. of Well Excavation oQ <br /> _ Domestic/p'rivate 1 Drilled,, Dia. of Well Casing °O <br /> Domestic/public Driven Ga! ge- of, Casing <br /> I Irrigation I Gravel -Pack Depth of Grout Seal <br /> Cathodic Protection ! Rotary ' Type of Grout <br /> Disposal I Other ,.. F Other Information <br /> Geophysical, Surface Seal Installed By,:_W,�„_ <br /> PUMP INSTALLATION; Contractor <br /> Type df PumpH.P. <br /> ;i <br /> PUMP REPLACEMENT: / / State Work Done # <br /> PUMP m:REPAIR: Erf State Work Done <br /> Va .,. <br /> ,SES-TRUCTION_OF WELL: Well Diameter Approximate Depth } <br /> - - Describe �Material and Procedure I <br /> k <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 mto the—best—of my kno d land belief. I WILL, CALL FOR AmGROUT INSPECTION <br /> PRIOR TO 2RgUZING. AND A FINALMMM INSPECTI <br /> SIGNED E <br /> DRAW ?LYK PLAN?O�N REVE E SIDE <br /> W MIK DEPARTMENT USE ONLY <br />)PHASE I / <br /> APPLICATION ACCEPTE Y DATE L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> -INSPECTION BY DATE INSPECTION BY DATE !d l r <br /> 1 E H. 1426 Rev. 1-74 1-74 2M : <br />