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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR .0 E: 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 ADDRHSSJ CATION . ' CENSUS TRACT <br /> Owner's Name ;r F ,-. Phone �� ®/ <br /> Address .� ,. « .. City <br /> Contractor's Name License #Tjj 'Phone <br /> - -=� <br /> TYPE OF WORK (Check): NEW WELL% / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT [7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK fSEWER'LINES/4pt PIT PRIVYO <br /> SEWAGE DISP SALIFIELD CESSPOOL/SEEPAGE PITA OTHER <br /> PROPERTY LINF.IgOPRIVATE DOMESTIC WELLA4*&VC-PUBLIC DOMESTIC WELL-, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> "Zgn <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 'r <br /> >/ Irrigation / Gravel Pack Depth of Grout Seal ,�/Z <br /> `''� Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information / <br /> Geophysical Surface Seal Installed By: JRle, 0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / f State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRIJCTION OF WELL: Well Diameter Approximate Depth <br /> AjiLe Describe Material and Procedure <br /> �t�4lL/7w4eJ?4-Xe M <br /> I hereby agree to comply witfr all law 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 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 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED -`;2 � .,; ; ' TITLE <br /> (DRAW -PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 110. DATE NSPECTION BY % DATE 3 -3o-,?r <br /> e 7-78 <br /> E H 1426 Rev. - 1-74 -LW L'.,Wyte..4 <br />