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�O'tc p1m �o� SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> �FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> 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 Zj 2/-7 <br /> a (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. X9.0.7 GU2�6-r-Ab CENSUS TRACT <br /> �^ !� i <br /> Owner's Name cog Q �ra, ,� <br /> Y- C� Phone <br /> Address 9,0 7 10 <br /> city -C16 <br /> Contractor's Name - - _ License # - !! 'hone 7676 <br /> �v_ <br /> TYPE OF WORK (Check) : NEW WELL /^/ DEEPEN/- 7 RECONDITION /7 DESTRUCTION _/-7 _ <br /> PUMP INSTALLATION / / DUMP REPAIR /y PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT __ OTHER <br /> PROPERTY LINE -- PRTVATE DOMESTIC WELL -_-, PUBLIC DObfESTIC WELL <br /> INTENDED USE _TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �� Industrial - j a Cable Tool Dia. of Well Excavation <br /> X� Domestic/private Drilled Jia. of Well Casing <br /> Domestic/public a Driven Gauge• of Casing <br /> i <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 <br /> PUMP INSTALLATION: Contractor _ O/-/ i�e <br /> Type of Pump _ S'ar� sir i(�' �f/,E, 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 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 GROU'1 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I CTI9 <br /> SIGNED Z, -, _ TITLE <br /> (DRAW PLOT PLAN ON Yt)3VL'RSE SIDE) <br /> ;i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE la <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS T T/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �l <br /> r <br /> E 11 1426 Revv!7.7 . f <br /> . � 1-74 2M_ _ _ � <br />