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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,'OFFICE USE: 1601 E. IlHazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION AOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y-i9-7v <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 desc'ibed. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the ltu sand V� Regulations of the San Joaquin Local Health District.j �y //1 CENSUS TRACT <br /> JOB ADDRESS/LOCATION..�J / � / <br /> Qwner's Name Ode Phone d <br /> Address ! '4 LIh City <br /> 11 <br /> Contractor's Name ��� License �-?7Phone 10?4P <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN '/? RECONDITION /-T DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> Ip <br /> DISTANCE TO NEAREST: SEPTIC TANK Zo SEWER -LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINit- - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Crable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing 10 <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 11 Rotary Type of Grout <br /> Disposal !i Other Other Information <br /> Geophysical 1� I Surface Seal, Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> k--PUMP-:REPA1-R:-- -- ...1-7—'"Sta'te-(Work-D&fe <br /> ES;TRUCTION OF WELL: Well ,Diamete�r 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 /> information is true to the best of; my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING Mp. A FINAL IN PECTION. <br /> SIGNED iM TITLE <br /> r f J1' DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY vV N.-� � WV Xv DATE 7 <br /> ADDITIONAL COMMENTS: I JI• <br /> P I GROUT .INSPECTION PHASE 1TI FINAL INSPECTION <br /> L INSPECTION BY DATE ;�Q-7„ INSPECTION BY DATE <br /> 'l E H 1426 Rev. 1-74 1-74 ,2M <br />