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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_R.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G <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 �j �,F, rCENSUS TRACT <br /> Owner's Name Phone 93��—_Fl rl <br /> Address T �, .2 2- City fie- f <br /> Contractor's Name 4DOX License #/ 2 73 Phone_3(, -,r ~+� <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN -/-7 RECONDITION /? DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> R PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 9' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> .,Domestic/private Drilled Dia. of Well Casing \ n <br /> bomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth-of Grout Seal <br /> Cathodic Protection Rotary Type of'Grout \� <br /> Disposal Other ;� Other Information <br /> Geophysical Surf ace Seal Installed B <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. -6— <br /> PUMP REPLACEMENT / / State Work Done <br /> 'UMP_REPAIR: 4� State Work Donee Y <br /> Al_ .a.a <br /> DESTRUCTION OF WELL: Well Diameter r' 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 rue to the•best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO rmoqUb ANR A VIM INSPECTION. <br /> SIGNED TITLE <br /> D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. t <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: / <br /> PHASE II CTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE AINSPECTION BY DATE t/-/2 •�6 <br /> __. <br /> E H 1426 Rev. 1-74 4/75-_ 2M <br />