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SAN JOAQUIN LOCAL IALTH DISTRICT I <br /> FORIOFFICE USE: 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 `/�2 <br /> (Complete In Triplicate) �— <br /> Application is hereby made to the San Joaquin Local- Health Disttict 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 Regulatioris• of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION erzijs z1VACENSUS TRACT <br /> Owner's Name Phone <br /> Address City .� <br /> Contractor's Name - ,,; „� License #6947961V Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTIONf7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -- 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �,�-- PROPERTY=LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDIED iTSE TYPE OF WELL _-._:CONSTRUCT-ION-SPECIFICATIONS <br /> Industrial Cable Tool Dia. ,of Well Excavation A <br /> Domestic/private Drilled Dia. ,of Well Casing <br /> Domestic/public _ 'Driven Gauge of Casing. <br /> Irrigation Gravel Pack Depth of .Grout Seal <br /> WwCathodic-Pr otection•' ' - Rotary Type of Grout <br /> Disposal � � Other Other Information <br /> Geophysical �:.� Surface Seal Installed By: <br /> PUMP INSTALLATION: k Contractor, <br /> •� T • e -o£ Pik r - H.P. <br /> yP r. <br /> PUMP REPLACEMENT: / State Work Done <br /> W r-L 1, jT a 4,LP 46 &CAI AJ86e- <br /> PUMP-,. <br /> 6 <br /> PUMP:REPAIR: -_� '%� State Work Done _c <br /> LES;TRUCTION OF WELL: Well Diameter - y " Approximate Depth <br /> Describe Platerial and�Procedure <br /> r <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 regulat.i.ng well construction. Within FIFTEEN DAYS <br /> after completion of,my work on a new well, I wilesfurnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPOR$,,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 'GROUT INSPECTION <br /> PRIOR TO GROUT"G AND A AL SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I��2�E4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9-!l- 7 C,( <br /> ADDITIONAL COMMENTS: - �— <br /> PHASE II GROUT INSPECTION PHASE I1 SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �, DATE � -tj' `�c/ <br /> ,w <br /> E H 1426 Rev. 1-74 1_7A AS <br />