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O d / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70 S/3 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a-/,5--ffc <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 <br /> Z�/ /j,4 � <br /> CENSUS TRACT <br /> Owner's Name Ml S' L <br /> F r Phone <br /> Address �r// <br /> / r city_�G <br /> Contractor's Name 45- 0/1 License #;�Q� <br /> Phone <br /> �4 � <br /> TYPE OF WORK (Check): NEW WELL/7 DEEP CONDITION /7 DESTRUCTION /'7 <br /> PUMP INSTALLATION /-7-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 I/ Cable Tool Dia. of Well Excavation <br /> _4Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 �^ <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: / / State Work Done <br /> PUMP :REPAIR: /._7 State Work Done _ <br /> PES-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 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 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 OUTING A IN INSPECTION. <br /> SIGNED TITLE �r� r <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA E II RO INSPECTI N PHASE III/FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE <br /> ti E H 1426 Rev. 1-74 1-74 2M <br />