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Co / SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FQRa.0 --ICE USS.. I/ 1601 E. Hazelton Ave. , .Stockton,,Calif.' <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -/j6 S` <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 /> ,TOE ADDRESS/LOCATION �� l CENSUS TRACT <br /> Owner's Name S Phone <br /> 40 <br /> '1 <br /> Address:,_ jIS v City Q07 <br /> Contractor's Name License # ,/1-;_2t4 P <br /> hone <br /> l <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN -/7 RECONDITION /_7 DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION /—/ PUMP REPAIR X-7 pump REPLACEMENT /7 <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT: PUBLIC DOMESTIC WELL _1J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �{ <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> X_ Domestic/private I Drilled* Dia. of Well Casing <br /> F " Domestic/public I Driven _` Gauge of Casing <br /> k Irrigation i Gravel Pack Depth of Grout Seal <br /> 4 Cathodic Protection F Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal. Installed By: � <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> i <br /> PUMP '.REPAIR: / / State Work Donen ,�, -. a/,r•�✓,e? C?r� /q• „ <br /> PES•TRUCTION_ OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F <br /> 1 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 the before putting- the- well in.use.. The above <br /> information is true to the-best of my- l ed and <br /> n lief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G U- ING .AND jA FINAL' INSPE <br /> SIGNED TLE - <br /> Y (DRA PL P ON RSE SIDE��. - - <br /> leg DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � , DATE . ID <br /> ADDITIONAL COMMENTS: ,.. <br /> PHASE II GROUT INSPECTION PHAS I FINAL INSPE <br /> INSPECTION BY DATE INSPECTION BY <br />(i 1 E H 1426 Rev. 1-74 1-74 2M <br />