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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR?OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7���� <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 /> JOB ADDRESS/LOCATION CENSUS TRACT cam' <br /> Owner's Name L Phone <br /> Address Ci <br /> ty <br /> Contractor's Name 1P Ifs License # �L Phone 2 - <br /> TYPB OF WORK (Check): NEW WELDDEEPEN /.�`1tECONDITON-/ I STRURION <br /> PUMP INSTALLATIQN K/,�K1PUMP REPAIR, FT')Aa EMENT /7 <br /> Other / / j _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE-DISPOSAL-FTELD --CESS.PMO SEEPAGE PIT *`�- OTHER �~ <br /> -.FAViER-TY LINE PRIVATE DOMESTIC WELL`"'�` PUBLIC DOMESTIC WELL 4 ; <br /> INTENDED USP," V-St TYPE OF 1GONSTRUCTION SPECIFICATIONS C� <br /> Industrial Cable Tool Dia. of ell Excavation <br /> Do:uestic/private ���Drilled Dia. of kelk Casing �• <br /> Domestic/public Oji ev n Gauge oft Casing "a <br /> Irrigation Grave,-Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geoihyiical 'Surface Seal Instal By: <br /> PUMP INSTALLATION¢ <br /> ContractAr <br /> Type of dump <br /> PUMP REPL�A.., NT: / / S to Work Done <br /> PUMP .� � �.' •-. ... _ -„--. <br /> `.R' PA /� State Work Done ppi <br /> RD <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe-Material and Procedure <br /> I hereby agree to comply with ag 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 Anew 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 CALL FOR A GROUT INSPECTION t <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> 0 E TMENT USE ONLY i <br /> PHASE x <br /> APPLICATION ACCEPTE _ Ci�C DATEg <br /> ADDITIONAi. PHASE II II GROUT INSPECTION - SHA E 1II FINAL INSPECTION <br /> INSPECTION " Y�rATE' ;" `INSPECTIL}N B DATE ,-,�(�jt,/ " <br /> �1 E H 1426 Rev. 1-74 7-74 9M'" <br />