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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR--OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�- <br /> k <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION ��� � _-_- CENSUS TRACT <br /> Owner's Name 7 �VAll-)RIA 1 Z �A)S .'— Phone <br /> f Address 710'0 .L2 jzC 11 f/lJ City S �lr%"Oly <br /> s - <br /> Contractor's Name �' F License # Phone ,?-3 3 <br /> s• <br /> TYPE OF WORK (Check): NEW WELL T DEEPEN/7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT 1 <br /> � Other <br /> t <br /> DIST4NCE •TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 71- SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE -• PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> .INTENDED USE TYPE OF WELL A ; CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of. Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing T ' <br /> Domestic/public Driven # `"Gauge 'of- Casingl t .e <br /> Irrigation Gravel Pack Depth o€ Grout Seal y 5V <br /> Cathodic ProtectionRotary Type of Grout C <br /> Disposal Other Other Information t I <br /> Geophysical Surface Seal-Installed- B t— <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump:-.. H.P. <br /> 1 <br /> PUMP REPLACEMENT: � i . �_.. - <br /> State Work Dane <br /> i . , , . ..,,. a. � R <br /> PUMP !REPAIR: /� State Work Done f, T <br /> LES-TRUCTION OF WELL: Well Diameter Approximate Depth bi <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 /> M after completion of my work on a new well, I will furnish the San Joaquin Local Health District a-Ei <br /> WELL DRILLERS REPORT of the well and notify them before putting.the. well'in.use.. The-above w <br /> information is true to the-beet-of my-knowledge and belief. I WILL CALL FOR A GROUT-INSPECTION <br /> PRIOR ROUTING AND A Fift INSPECTION. <br /> SIGNED TITLE <br /> k (DRAW PLOT PLAN ON REVERSE SIDE) <br /> { FOR DEPARTMENT USE ONLY <br /> 1 PRASE I <br /> APPLICATION ACCEPTED BY DATE D 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHAS9 II GRPUT INSPEG2qON PHASEII F AT, INSPECTIO <br /> INSPECTION BY DATE /� /U INSPECTION BY DATE 2 <br /> t E H 1426 Rev. 1-74 1-74 2M C05. <br />