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lk <br /> Cam In' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFF CE USE: 1601 E. Hazelton Ave. Stockton Calif. <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 <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 g-pp / � dG� „ „ CENSUS TRACT <br /> Owner's NameT. ,v} Phone <br /> Address C.p S /���+�t>!� City � t AulelC4 <br /> Contractor's NameLicense #11a7lol Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /e <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 Q <br /> Domestic/public Driven Gauge of Casing p <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 By: 6r <br /> PUMP INSTALLATION: Contractor ) g�__ _ <br /> Type of Pump / of �'ty ra!�era�'o .r�„�T H.P <br /> PUMP REPLACEMENT: / / State Work Done X14 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Jaws 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 thewell in use. The above <br /> information is true to the best of my.-kn wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I AE; wION. <br /> SIGNED TITLEj�t. <br /> { PLOT PLAN ON(REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 041 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIGROUT-IRSPECTIOV. PHKSE4j1X1FIN4 MVECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - }= 77 <br /> E H 1426 Rev. 1-74 '�^- <br />