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SAN JOAQUIN LOCAL HEALTH:_DISTRICT <br /> FOR OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> �4 + <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _7 <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 he Rules and Regulations of the San Joaquin Local Health District. . <br /> { <br /> Jul ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's <br /> Owner's Name ✓ '' 1 �"" ® ' A Phone l <br /> Address s Cit <br /> Contractor's Name License�23 Phonb 6!0;1 <br /> TYPE_OF 'WORK (Check) . Y NEW WELL '/ / - DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other 17 <br /> f 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD '° CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ' Dia, of Well Excavation "U <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ,. Driven Gauge of Casing <br /> Irrigation J Gravel Pack Depth of Grout Seal11 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other,'.Information--` r <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r, <br /> PUMP .REPAIR: _ ]`�( State. Work..Donki <br /> - <br /> • �� r- - <br /> DESTRUCTION 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 /> information is true to the best of my. knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLERQc <br /> - - .! :- .:is � '. F.gf,••i`;I <br /> (DRAWPLOT PLAN" RE FRSE SIDE) R } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY -- - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION : ' PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> 3/745M <br /> E H 1426 Rev. 1--74 <br />