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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. -7 7 oz./- P <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No. 7 ....= <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7-7- 7 7 <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 uJ CENSUS TRACT <br /> Owner's Name Phone <br /> s City lr � <br /> Address ,�� <br /> Contractor's Name /il//4RG� �� �� License <br /> i <br />* TYPE OF WORK (Check) : NEW WELL: DEEPEN/ / RECONDITION f_1 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR j j PUMP REPLACEMENT j-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE PAGE PIT OTHER <br /> PROPERTY LINE-Lf-PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ,z 417 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation < Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout = <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor r �; <br /> Type of Pump `/ H.P. <br /> .i PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> .L: DE5-TRUCTION OF WELL: Well- ammeter Approximate Depth <br /> :'. Describe literial and Procedure <br /> I hereby agree to comply "with all laws end regulations of the San Joaquin Local Health Dist ct <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a"naRwell, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT a well and notify them before putting the .well in use. The above <br /> information is tr to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU P ION. <br /> SIGNED �1 TITLE <br /> DRAW PI. T PLAN ON RE ERSE SIRE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I OU 7 SPECTION PHASE I Ij NAL INSPECTION <br /> INSPECTION BY DATE 7 INSPECTION BY DATE <br /> Z. 7 7 3/76 2M <br /> E. H ,1426 Rev. 1-74 <br />