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% SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE"FUSE: 1601E. Hazelton Ave. , Stockton, Calif. <br /> :. Telephone: (2'09)w466-6781 <br /> PLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-7 <br /> ON <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z6-19- <br /> (Complete <br /> 6 19-(Complete In Triplicate) <br /> Application is hereby made to the' San Joaquin 'Local Health District for a permit to':coistr"uct <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 CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> .. u. <br /> Address Cityf <br /> Contractor s •Name <br /> ' License #`. Phone <br /> t i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN // RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWjR LINES 357 PIT PRIVY <br /> : y SEWAGE DISPOSAL FIELD $5' CESSPOOL/SEEPAGE -PIT OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELLAZO PUBLISC,.'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIk SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Nf <br /> '� .; <br /> Domestic/public , Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth Qf Grout Seal - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Ry' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: <br /> DES•TRUCTIOM OF WELL: - Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> N ` <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 GROUT INSPECTION <br /> PRIOR TOG UTING AND FINAL- PECTI N. <br /> SIGNED ITLE � <br /> D PLT LAN ON E SIDE) <br /> I ; <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ,APPLICATION ACCEPTED BY DATE I1 ,6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> IN BY A41 DATE v_ (!�, INSPECTION BY DATE <br /> 3/6 <br /> E H 1426 Rev. 1-74 — <br />