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SAN JOAQUIN LOCAL HEALTH DISTRICT rK <br /> F0r, OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. QY <br /> Telephone : (209) 466-6781 'f <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 R es and Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/L C ON �j 6t2 CENSUS TRACT <br /> , 066 ��,7 <br /> Owner's Name n�] Phone <br /> Address ) s` Cit <br /> Contractor's Name License �'32-BPhone4a1-9� ' <br /> TYPE OF WORK (Check) ; NEW WELL /DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / { <br /> Other <br /> DISTANCE TO=NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT NS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4e7 � f <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout " <br /> Disposal Other Other Information , <br /> Geophysical Surf <br /> ace Seal Instal <br /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. f <br /> PUMP REPLACEMENT; / V/' State Work Do <br /> PUMP:REPAIR: _ <br /> / T State Work Done_' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia. and Procedure <br /> 3 <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 CALL FOR A GROUT INSPECTION <br />'RIOR TO G 0 TING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> t, FOR DEPARTMENT USE ONLY <br /> PHASE I �,/ <br /> kPPLICATION ACCEPTED BY 5.5� DATE <br /> ADDITIONAL COMMENTS: ` r. <br /> PHASE II,/ UT TftPECTION PHASE /F AL INSPECTIO <br /> CNSPE ION BY ATE INSPECTION BYe' DATE 3ZL <br /> lo— It <br /> P u i z n_-- µ` 61, t� /1t ati 1 1 177 mar tte <br />