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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: LZ1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7,7- /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y/,�-7 <br /> 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 ILl3 -3 07 CENSUS TRACT 20(p---060- ,01 <br /> 10 <br /> Owner's Name 7 Phone " <br /> Address City <br /> Contractor's Name License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION / _ <br /> AL _/ DESTRUCTION / <br /> PUMP INSTLATION / / PUMP REPAIR I / PUMP REPLACEMENT- / <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 PU]kIC DOMESTIC .WELL <br /> INTENDED USE TYPE "OF WELL CONSTRUCTION 'SPECIFICATIONS w <br /> Industrial Cable Tool Dia.- df Well Excavation R' <br /> Domestic/private Drilled Y Dia. of Well Casing t" <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 5u"rface,-S-ealInstalled By: <br /> PUMP INSTALLATION: Contractor <br /> i tl <br /> Type of Pump H.P. 0 G <br /> PUMP REPLACEMENT: State Work Done i <br /> �a <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-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. kno edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND INAL INSPECTION <br /> SIGNED TITLE <br /> QYRAW LOT P 'ON REVERSE SIDET <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY yzz DATE <br /> ADDITIONAL COMMENTS: T <br /> PHASE II G OUT INSPECTION PITASF41II/FIN.AL INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE <br /> L <br /> E H 1426 Rev. 1-74 3/76 2M <br />