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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO .OFFICE USE: 1601 E. 11azelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 `/ p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-- `7-� 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 and the Rules and Regulations of, the Sass Joaquin Local Health District. <br /> /1 cr? g, x • F(6�Lr'-E t LF—. 74 r^: V 7 I-- MVI fa 2— <br /> JOB ADDRESS/LOCATIONS.' ML,�, CENSUS TRACT <br /> Owner's NameLPhone [_ -- <br /> Address 9' S— 64." ` .� <br /> City <br /> Contractor's Name License #1/6,_Z,37.3 Phone P4 - <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR Ag PUMP REPLACEMENT /7 <br /> Other / 7 <br /> DISTANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 ` H.P. <br /> PUMP REPLACEMENT: .. /_7 State Work Done <br /> PUMf.' ,,REPAIR: State Work Done T <br /> ,DES•TRUCTION 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 Joaqui.n.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 TO GRO IN AND AL INSPECTION. F <br /> SIGNED TITLE - <br /> (DRA PLOT PLAN ON REVERSE SIDE <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 21.0 DATE <br /> ADDITIONAL COMMENTS: -r-- <br /> PHASE II GRO P0 PHASE II INAL INSPECTION <br /> INSPECTION BY D INSPECTION BY 4dZ2 17jr' DATE <br /> E H 1426 Rev. 1-74 4/75 2M_ - <br />