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Ld wt lb' ( SAN JOAQUIN LOCAL HEALTH DISTRICT M <br /> FOR;OF CE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> , C li . <br /> ,. Telephone: (209) 466-6781 <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7S-(a <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 /> .SOB ADDRESS/LOCATION `cam CENSUS TRACT <br /> Owner's Name �A A 01 Phone <br /> Address C� <br /> � City 67�at play]ort.° � <br /> Contractor's Name License ! 3?� Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /7 RECONDITION /-j DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR'ZF 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•_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 ; <br /> Industrial Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia, of Well Casing <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 <br /> Type .of Pump H.P. 614 <br /> i <br /> PUMP REPLACEMENT: . / / State Work Done } <br /> PUMP :REPAIR: /7 State Work Done ; <br /> r- 4 <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 �1 <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. ow edgerand-belief.. 1a-'WILL CALL FOR A:GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL INSPX IO <br /> SIGN D r a TLE <br /> 4DEW PLOT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE' DATE ' / 7-5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BY 2 DATE <br /> E H 1426 Raw_ 7_74 1i/71� 9M <br />