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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G-1._5Z&I <br /> THIS PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED Date Issued ..?_7�, <br /> (Complete In Triplicate) <br /> Application is hereby made to the Salt 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 /> / <br /> JOB ADDRESS LOCATION:, CENSUS TRACT <br /> Owner's Name &i Phone <br /> Address 12Z2 422!2"Mv City �r -1✓ ll�/r' <br /> Contractor's Name N660e& _IAI&II yr jf S License -# Phone ' , 4 d,�w <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -17 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INS AL TION-PUMP REPAIR /7 PUMP REPLACEMENT 1 f <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 10,9 SEWER LINES eW PIT 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 __jable Tool Dia. of Well Excavation " 77— <br /> _J:�—Domestic/private Drilled Dia. of Well Casing r A <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal aQ <br /> Cathodic Protection Rotary Type of Grout e A <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done J <br /> PUMP :REPAIR: L7 State Work Done <br /> E&TRUCTION 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A,FINk INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDEJ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY C DATE / INSPECTION BY DATE <br /> JL <br /> ' E H 1426 Rev. 1-74 1-74 2M <br />