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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfl;OFFiCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "!,�-3 DtJ <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZ <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 stork herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 86 and <br /> the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name7610 -417 Ira 6&- bm'r/ofLicense # Phone / <br /> TYPE OF WORK (Check) NEW WELL Ly DEEPEN/_7 RECONDITION %T DESTRUCTION L7 <br /> PUMP INSTALLATION L-7PUNP REPAIR /_7 PUMP REPLACEMENT L7 <br /> Other L`7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �[ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGX'PIT OTHER <br /> !` PROPERTY LINE - PRIVATE DOME IC WELL PUBLIC DOMESTIC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WellL Excavation <br /> Domestic/private Drilled Dia. of Well Casing �• <br /> Domestic/public Driven Gauge of Casing &09 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ✓ Rotary Type of Grout __.-._..._ <br /> Disposal Other �_ Other Information <br /> Geophysical Surface eal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L-7 State Work Done <br /> ��'A�IR: L7 State Work Done - - - <br /> AWRUCTION 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 ftstrict 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 ROUTING AND Ab FIN INSP ION. <br /> SIGNED TITLE <br /> KURAW PLOT ON E SIDE <br /> -FOR DEPARTMENT. USE ONLY <br /> PHASE .I <br /> AP ION ACCEPTE B DATE <br /> ADDITIONAL (062 <br /> P I INSPECTION P II F AL INSPECTION <br /> INSPECTION BY DATE INSPECTI DATE �✓7�' <br /> , 8 H 1426 . Rev. 1-74 1-74 ZM <br />