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7 SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOL:ZFFICE USE: 1601 E. Hazelton Ave. , Stockton, CaliT.' - '� <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6- <br /> THIS <br /> 6-THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB -ADDRESS/LOCATION /r u '`" CENSUS TRACT <br /> Owner's Name Phone <br /> Address 1 City . <br /> ' `1/�� " . r License Phone ./ . <br /> Contractor's Name <br /> , t , <br /> r <br /> TYPE OF WORK (Check): NEW WELL/ BEEPEN '/� RECONDITION /_� DESTRUCTION I� <br /> PUMP INSTALLATION ", :: 'J H' REPAIR,/7 PUMP REPLACEMENT - /7. <br /> Other <br /> DISTANJCE TO NEAREST: SEPTIC TANK 1.!. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSE FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 6\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> strial able Tool Dia. of Well Excavation <br /> f Domestic/private. Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> n" T e of Grout <br /> Cathodic Protection' Rotary Type — <br /> Disposal Other Other Information <br /> ' Geophysical Surface' Seal Installed 'B <br /> 4 <br /> PUMP INSTALLATION: Contractor 001, '" ~ _ `•` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State-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 '•constxuction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I-will furnish the San,doaquin Local 'Health Distriet�,a' <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well. in.use..,. The above xx:: <br /> information is true to the•best of my. knowledge and belief. .1 WILL CALL .FOR.A"GAOUT- INSPECTION <br /> ,} <br /> PRIOR TO GROUNG A FINAL INSPECTIO ` ; <br /> Z <br /> SIGNED TITLE <br /> DRAW PLOT PLAN, ON REVERSE .SIDE <br /> FOR DEPARTMENT USE ONLY- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE In4/ <br /> F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1-7—Z.? <br /> h/75 2M <br />