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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�G� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE:ISSUED Date Issued /-_._ J.0 <br /> (Complete In Triplicate) <br /> Application is hereby made 'to the San ,Joaquin Local health District for a permit to construct <br /> f and/or install the work herein described. This appllcation 'is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San ,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �1�- U —� CENSUS TRACT <br /> 6� <br /> E Owner's Name Phone <br /> Address ` City -�- 1 <br /> Contractor's Name It License # / Phone 4 � Y <br /> F <br /> M TYPE OF WORK (Check): NEW WELL DEEPEN 'j-' RECONDITION /7 DESTRUCTION <br /> PUMP INSTAL TION "/// PUMP REPAIR / Pump REPLACEMENT /7 <br /> Other / /' <br /> F1 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> PROPERTY LINE - PRIVATE DOMESTIC WELD" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial- 11 Cable Tool Dia. of Well Excavation 4 <br /> �Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation <br /> asing Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection c`Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor C <br /> Type; of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / 1 State Work Done <br /> DES-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 these before,, <br /> utting the..we11. 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 2ROUTING AND NAL INSP CTIOF : <br /> SIGNED TITLE J <br /> �< (DRAW T PLAN ON REVERSE SIDWA C j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GRO INSPECTION PHA II INSPECT ON <br /> INSPECTION BY .p <DATE, INSPECTION BY E <br /> k,_ E H 1426 ' RaYy_ 7_7G f ' 11/7q 2M <br />