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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. 7f- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z--7 -7 <br /> 7d <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 Jopquin : <br /> County Ordinance No. 1862 and the, Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j CENSUS TRACT <br /> Owner's Name <br /> IaLl-L Phone <br /> _ED 17- <br /> Address ZAddress City �CG1-e7-_e4j <br /> Contractor's Name �j` ���` W / , License Z Phone <br /> 4 <br /> a <br /> TYPE OF WORK (Check): NEW WELLDEEPEN %// RECONDITION %/_:DEST-RUCTION-- .. <br /> y. PUMP INST LATI®N %I PUMP REPAIR-`// ; PUMP REPLACEMM— FTOther = ' <br /> DISTANCE TO NEAREST: SEPTIC TANKf ; <br /> � SEWER'LINES T PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,- CESSPOOL/SEEPAGE PIT OTHER 1- <br /> P-ROPERTY'L M' - . VATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE <br /> TYPE OFfWELL CONSTRUCTION SPECIFICATIONS, <br /> Industrial ��' Cable Tool Dia_ of Well Excavation � <br /> Domestic/Private- Drilled Q °f <br /> Dia,. of Well Casing <br /> Domestic/public Driven Gauge of Casing f : <br /> I troth , nz'"rot <br /> ,+� Gravel Pack Depth of Grout Seal rp F <br /> Cathodic'Protection =/ RPtary_._ Type of Grout <br /> Disposal moi` Other Other InformationGeo .. -... <br /> Phys{cal Y Surface Seal Installed B : " <br /> PUMP Contractor <br /> INSTAI,LATI033d; ' <br /> _ <br /> d -. `` Type of Pump �...- ,.�-'- r - _ I <br /> �.. <br /> PUI9P'REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: y/�/. State Work Done <br />)ESTRUCTION OF WELL: Well Diameter v Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> L 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 /> BELL DRILLERS REPORT of the well and notify them before putting the. well in use. The above <br /> Cnformation is true to the best of- my kno►iledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br />'RIOR TO GROUTING AND A F SPECTION. <br />;IGNED ' <br /> TITLE , a <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 4 <br />'RASE I <br />►PPLICATION ACCEPTED BY DATE <br /> 1DDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE F AL INSPECTION <br /> INSPECTION BY —----DATE --r INSPECTION BY <br /> E H 1426 Rev. 1-74 1177 � � <br />