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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` l <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 <br /> THIS. PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued <br /> (Complete InTriplicate) <br /> i 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 7. ] p x�� 7 CENSUS TRACT-' T- <br /> Owner's Name 4 ,� d rte' �/ �'"Q' n�� �*. -- Phone <br />[ f <br /> Address "� " � �2. �v'cl�rs- r _ City �'c�a,if <br /> Contractor's Name _r. Ft License # /jA_7xx{`Phone <br /> TYPE OF WORK (Check) . NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> . PUMP INSTALLATION / / PUMP REPAIR / !/ PUMP REPLACEMENT <br /> other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> X Industrial Cable Tool Dia. of Well Excavation <br /> >c 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor e <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 � <br /> r PUMP .REPAIR: /)Q State Work Done �q <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.... The above <br /> j information is true to the best of my knowIedge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL I P VT <br /> SIGNED TITLE -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT. USE ONLY <br /> f PHASE I <br /> APPLICATION ACCEPTED BYp. DATE <br /> ADDITIONAL COMMENTS: <br /> f PHASE II gROUT INSPECTION ' PHA E . /F AL INSPECTIO <br /> INSPECTION BY &ZDATE INSPECTION BY, DATE 2, ,Z3 <br /> v�77 2M <br /> E H 1426 Rev. - I-74 _ <br />