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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <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 <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 an-d,t,1u3.-e and Regulations of the San Joaquin Local Health Distract. <br /> �� <br /> B re <br /> ADDRESS/LOCATION r SQ, a <br /> D , � CENSUS TRACT <br /> r p� <br /> Owner's Name t`" �c.�Phone <br /> Address City <br /> 6A0_,e1-,0,�ef <br /> Contractor's Name f <br /> - License #cx - Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTAN E 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 R) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �ndustrial Cable Tool Dia. of Well Excavation / _ <br /> omestic/private Drilled Dia, of Well Casing ��j u Q <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 I V H.P. <br /> _ a <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 est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UT G D A VWu SPECTION. <br /> SIGNED ZZA TITLE f <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Ld —/-2- • Z2. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 72 <br /> E H 1426 Rev. 1-74 1/17 2M <br />