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SAN JOAQUIN LOOffi--REALTH DISTRICT <br /> F0-VSF'FICE USE: 2601 E. Haseltoa Ave., Stockton, Calif. <br /> Telephone:: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 41 <br /> THIS PERMIT..,EXPIRES 1 ,YEAR PM DATE 'ISSUED Date Issued'; Oe4 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local-."Health-District fore a.patmit to 'construct <br /> and/or install the work erein :descr PP& This 4pplicat10,0 49 made in compliance with-San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations 'of ,the San- JoaquiwLocal Health= Diotrict. <br /> JOB ADDRESS/LOCATIONALL <br /> CENSU91ITRACT. <br /> thneer's Name Phoned S1� <br /> d ` ;a . v _ <br /> Address- ,..� " City. ... <br /> 737M <br /> Contractor's Name License # Phone 913 e— a <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/ RECONDITION /7 DESTRUCTION s__7 <br /> PUMP INSTALLATION L^7 PUNS' REPAIR /-7—PUMP REPLACEMENT <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK (,4 '_ SEWER LINES PIT PRIVY <br /> SEWAGE--DISPOSAL FIELD CESSPOOL/SEEPAGE PITS OTHER <br /> PROPERTY LINE PRIMATE DOMESTIC WELL PUBLIC DOMESTI WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFiCATIQN$ <br /> Industrial -Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled ,, Dia. of Wall Casing <br /> Domestic/public Driven Gauge of :Casing / e(- <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection Rotary Type of`Grsut <br /> Disposal Other Other Information <br /> _,Geophysical Surface Seal Installed Bv: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r HOP* <br /> PUMP REPLACEMENT: E/ State Work Done <br /> j <br /> PUMP :REPAIR: L7 State=Work Done <br /> ,,ESS UCTION OF WELL: Well Diameter c/// Approximate Depth ! r <br /> Describe Materialaqd Procedure <br /> I hereby agree to comply with all laws and regulations of he S Joaq 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. j WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE DATE//f y/6 ! ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,_ DATE ,o -A" <br /> �-,2 <br /> E H 1426 Rev. -1 74 <br /> 1-74 2M <br />