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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO .'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit,No.7 7—/M2., <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _O'cl F, (f ,LE FRENCH CAMP CENSUS TRACT <br /> Owner's Name J_0HA/ /UZZ T,--NS9UZ- <br /> Phone <br /> Address A E <br /> City �NCy C rh <br /> Contractor's Name /OAC �pUjyje�.LAI <br /> C - License #,Zp_�79y Phone 8- $/ <br /> TYPE OF WORK (Check)': NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK p" 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 za <br /> XW Domestic/private Drilled Dia. of Well Casing r� <br /> Domestic/public Driven Gauge of Casing E; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection --- e Rotary Type of Grout E�/Ta/U/T� <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: O1¢C/� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P <br /> .Hip. <br /> :H <br /> PUMP REPLACEMENT: State State Work Done MQV16 40MO0 L G d aJ� <br /> PUMP .REPAIR: / / State Work Done 3 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure a 7 <br /> I hereby agree to complyw th 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 DAIS <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 TO GRO NG D A INAL IN ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I §K1 <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/F NAL INSPECTION <br /> INSPECTION BY ,� DATE Xo r. A77 INSPECTION BY _ DATE /,,p. <br /> E H 1426 Rev. I-74 if 77 2*%, <br />