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SAN 30AQUIN LOCAL HEALTH DISTRICT � <br /> -FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELi�­,CONSTRUCTION OR PUMP PERMIT Permit No, 7 - Z 70 <br /> 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 Ordinance862 and the ules an Reg lations of t e San Joaquin Local Health District. <br /> Wit,���•... � <br /> JOB ADDRESS/LOCATION ?,j�ENSUS TRACT <br /> Owner's Name /�G -c-� ��'�-G� Phone <br /> Address 4.9a 4 Citi <br /> i <br /> j �.- I <br /> Contractor's Name (.f < Q`� License ��� Phone ZW I <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPU /_/ RECONDITION /� DESTRUCTION /_7" <br /> AL <br /> PUMP INSTALLATION X/ PUMP REPAIR /—/—PUMP REPLACEMENT F7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done.' <br /> 4 <br /> PUMP ,REPAIR: / / State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 t e best of- my knowledge and belief. I WILL CALL,FOR A GROUT INSPECTION ` <br /> PRIOR TO G TING AND FINAL NSP ON. �/ <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> DEP TMENT USE ONLY ; <br /> PHASE I <br /> APPLICATION ACCEPTEDY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FI- AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE tr <br /> h <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />