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SAN JOAQUIN LOCAL• HEALTH DISTRICT <br /> FOE OFFICE USE 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued --71 <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 S n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / CENSUS TRAGI' - <br /> Owner's Name Phone ' <br /> Address �� , City <br /> - <br /> Contractor's Name 4 *, ` a t License #AXO&& Phone <br /> a <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACElW 7 ' <br /> Other /_7 <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 C. <br /> Domestic/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 Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor ?77wCi-i <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Doa �[`*-• �T <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 laws and regulations of the San Joaquin Local Health istriel <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 CAL F08 A GROUT INSPECTION <br /> PRIOR TO GRO ING AND NAL INSPECTION. <br /> SIGNED TITLE r.Q�• • .. - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY6L;�C4� DATE 7 '77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1 f Z7" `. .2M <br />