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SAN JOAQUIN LOCAL HEALTH DISTRICT. <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 CAL4,,O I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 017_ 05-0-0-7 <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. F <br /> C`�7. Qy ._Ny '.)E.rccr�� ' �r�� <br /> JOB ADDRESS/LOCATION Wed sr e; � c � CENSUS TRACT s <br /> Owner's Name. s4a a 0 arr Phone <br /> Address ,5� /� City <br /> Contractor's Name ac6 License # hone-AI- <br /> TYPE <br /> y 7G <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION /_' DESTRUCTION /_7 s <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT17 <br /> Other /_7 tO <br /> DISTANCE TO NEAREST: SEPTIC TANK= SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD "'4 CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS = <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled bia. 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 'Surface Seal Installed. By: <br /> • i <br /> PUMP INSTALLATIONS ContractoraG <br /> Type of Pump --'""" H.P. <br /> PUMP State Work Done <br />_ PUMP ;REPAIR: _ L7 State Work Done <br /> 29LIRUCTION OF WELL: Well Diameter v _ `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 knowled a andff .`bei of. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSP IO <br /> SIGNED ITLE <br /> D WLOT PLAN ON MSIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION .ACCEPTED BY DATE IL-1 <br /> ADDITIONAL COMMENTS: <br /> PRASE IIOUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE r S� <br /> W <br /> E H 1426 Rev. 1-74 1-74 2M <br />