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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 11� 77S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Joaqu, ' <br /> County Ordinance No. 1862 and the Mules a egulations of the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �/ CENSUS TRACT j <br />...Owner's Name Phone E <br /> Address /� O Id City ,�CA <br /> 1!A <br /> Contractor's Name -7 � / • -t, LiceArCnse �� <br /> �� QI D�Phone � <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPENRECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 1W PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / — - - <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANKe00' SEWER LINES /0 c) PIT PRIVY p-wc <br /> SEWAGE DISPOSAL FIELD ,4 G CESSPOOL/SEEPAGE PIT ,OD/ OT E R -�- --�— � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ` == PUBLIC DOMESTIC WELL <br /> INT13NDED USE TYPE OF WELL CONSTRUCTION SRECIFICATJIONS ; <br /> Industrial Cable Tool Dia. of Well Excavation t <br /> ie llomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> —, Irrigation 0 el Pack Depth of Grout S _1 <-V!/R <br /> Catr odic Protection otary Type of Grout I _ <br /> - Dis`posal Other Other Information <br /> -Geophysical Su ce Seal ;/M C ! <br /> PUMP INSTALLATION: Contractor <br /> Type of P H.P. '-1�/• '.�' <br /> I <br /> PUMA' REPLACEMENT:..:--- . ./../ State Work Done <br /> PUMP •.REPAIR: / / State Work Done i <br /> DES�TRUC_TION 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 <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 /> infor at is true to the be t' knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GR TING AND A .F. A IN I <br /> SIGNED t TITI9 c R f -- - <br /> PLOT PLAN ON REVERSE SM) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY �2 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR, UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATETzZ- <br /> E H 1426 Rev. 1-74 <br />