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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB,,O FILE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-S 931 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /_E <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. 3 <br /> JOB ADDRESS/LOCATION 6_900 _f - <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> Address 4 <br /> `i City " <br /> Contractor's Name <br /> License # / -- Phone <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN/7 RECONDITION /_7 DESTRUCTION /_7 <br /> � <br /> PUMP INSTALLATION '/ / PUMP REPAIR � PUMP REPLACEMENT � <br /> % Q <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 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 a <br /> DisPo$al - Other Other Information ' <br />-Geophysical Surface Seal Installed "B : <br /> PUMP INSTALLATION: Contractor - <br /> y Type .of Pump "'. H.P. <br /> PUMP REPLACEMENT: r / ;./ State Work Done <br /> PUMP `REPAIR: /kf, State Work Done . <br /> aESjRUCTION OF WELL: Well Diameter . <br /> V <br /> 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 CALI;'FOR A GROUT INSPECTION <br />'RIOR TO GROUT G AND A FINAL INSPE 'N. <br /> SIGNED TYLE <br /> (D W P T VLA ON RE RSE SIDE <br /> I. R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE " <br /> ADDITIONALiCOMMENTS: !i' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION1 BY 1 DATE <br /> w_ INSPECTION BY DATE , 6�7 <br /> AE H 1426 Rev. 1-74 5 <br /> � _. 1,/7� 7M� E <br />