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SAN JOAQUIN LOCAL HEALTH DISTRICTAgo <br /> FOk OFFICE USE: ,1601 E. Hazelton Ave. , Stockton, Cal" ' <br /> I' 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 <br /> (CompleteIn 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 ,N.o.- 1862. and ..the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATTION : {t ,l tA"' b r - CENSUS TRACT 050--0 <br /> Owner's Name I ��/�%/© T//� f/,( � �I� ��/l/G� Phone <br /> Address <br /> 'City <br /> Contractor's Name License # /764612- Phone <br /> TYPE OF WORK (Check) : NEW WELL / % DEEPEN '/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTAZLATION' / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY F <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 7Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> - Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1 Other Other Information 4 <br /> Geophysical <br /> . — Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> V9 i <br /> PUMP REPLACEMENT: / / State Work Done -9 <br /> s <br /> PUMP`-REPAIR: t _ _ . <br /> YS tate- Work Done <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 <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-_G_flOVTING AND FIN AI -INSPECTION. <br /> SIGNED -� <br /> TITLE � �✓�" <br /> s (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ` ` <br /> APPLICATION ACCEPTED BY / <br /> DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - -�, DATE <br /> E H 1426 ' Rev. - I-74 . 6/7.7 _ 2M , <br />