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lZ As- N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS 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 /> b <br /> ' 0 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ,V QLe Phone <br /> Address 27 2 Y67 L Z p,. g^"' <br /> City G-cr on/ <br /> Contractor's Name E - �- .License ISP hone <br /> F <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ f RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INST''A�LrLLLATION / J PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/�� 1 SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD .— CESSPOOL/SEEPAGE PIT OTHER —� <br /> PROPERTY LINE20PRIVATE DOMESTIC WELL/46(j/ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> Domestic/private rifled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation$ Gravel Pack Depth of Grout Seal v' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information G <br /> Geophysical '--' "SurfaC6-S-eal'-Inst6:l1ed By: <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump -- - ��,��.�r-s �, „....._.. _. H.P. . . � <br /> s <br /> PUMP REPLACEMENT: <br /> / / State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and -Procedure <br /> t <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 otify them before putting the .well in use. The above <br /> information 's true to thees o knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO O A FI A N E I - <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION. ACCEPTED. BY _ DATE Q8L7 . <br /> ADDITIONAL COMMENTS: k <br /> PHASE II-GROUT INSPECTION PHAS I I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> E H 1426 Rpt,_ I_7L 11177 <br />