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SAN JOAQUIN LOCAViiEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74/- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s_.is_-may <br /> (Complete In Triplicate) C<. <br /> C Application is hereby made to the San Joaquin Local Health Diat ict 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 Joa uin Local-Health District. <br /> JOB ADDRESS/LOCATION — L � <br /> . � � (� CENSUS TRACT S-5 S <br /> Owner°s Name L.�� Phone �q3 - 7 g(p <br /> Address . _ _ - City <br /> Contractor's Name icense #rQPhone��/( 3/ <br /> F <br /> �`-'"3. -..tis,.iF. �• AiF�c,vs:di+•-7,lTrr^.a.rw..®s,_ .wr•s,R.w...,...__y'Ir ..._.__ _�r:�.wwr -�.-'—'-' _ :.. l �' <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /_7 DESTRUCTION %j <br /> G, PUMP INSTALLATION / J PUMP REPAIR /7 .PUMP REPLACEMENT 1 f <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Cable Tool Dia. of Well Excavation 'r <br /> l Domestic/private Drilled Dia. of Well Casing <br /> �- Domestic/public Driven Gauge of Casing �, ...... �.l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' y <br /> Disposal Other Other, Information .. <br /> Geophysical Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump R.P. <br /> PUMP REPLACEMENT: /7 State Work DonePW--.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 <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 /> j PRIOR TO GROUTING AND F NAL INS CTIO <br /> SIGNED1 TITLE Ile llawl <br /> {DRA ALOT P ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 5/j-,1A 0-., <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I INSPECTION <br /> INSPECTION'BY DATE INSPECTI N BY DATE <br /> `3 E S,•142b Rev. I-74 <br /> 1-74 2M <br /> M- <br />