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#S9, JOAQUIN LOCAL HEALTH DISTRICT <br /> `OF OFFICE USE: 1601` . Hazelton Ave. , Stockton, Cali" <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 . <br /> IRES l YEAR FROM DATE ISSUED Date Issued37 <br /> THIS PERMIT EXP I I' <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ad/or install the work herein described. This application is made in compliance with San Joaquin <br /> aunty Ordinance No. 1862 and� the,�Rules Regulations of the San Joaquin Local Health District. i <br /> )B ADDRESSJLO T N CENSUS T CT ' . <br /> Phone <br /> � � <br /> Ener's Name <br /> a <br /> 3dresCity <br /> s JJ <br /> Dntractor s Name <br /> License/15/' a37-9 Phone�K 176 <br /> 0E OF WORK (Check) : NEW WELL / J DEEPEN/ J RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR J J PUMP REPLACEMENT /? <br /> Other <br /> !STANCETO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE —PRIVATE D014ESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 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 Other Other Information' <br /> Geophysical rface Seal Installed B <br /> UMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ C <br /> 'UMP REPLACEMENT. / J State Work Done <br /> ?UMP .REPAIR: / / State Work Done <br /> )ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON RE ERSE.SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3- J <br /> LLJ <br />'o ADDITIONAL COMMENTS: <br /> PHASE Ik OUT INSPECTION HAS I.E .` IN INSPECTIO <br /> INSPEGTION BY DATE INSPECTION BY �.���' DATE T <br /> . . _ 3/76 2M <br /> E H 1426 Rev. 1-74 _-_ - <br />