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s SAJOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 EN. Hazelton Ave. , Stockton, Calif. SCANNE <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7e-X.33 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S <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 , /LOCATION 491 i!� — "AmA e 4—:k6bes CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Uborrmafas ,� - "1/16Gi License #Ad' /.pphonej,L�_1,2) <br /> -_ y <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / RECONDITION /_7 DESTRUCTION /7 a <br /> PUMP INST LATION /x/ PUMP REPAIR / / PUMP REPLACEMENT /- + <br /> Other / / `� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` PIT PRIVY <br /> SEWAGE DISPOSAL YIELD CESSPOOL/SEEPAGE PIT/�t OTHER <br /> PROPERTY LINRIVATE DOMESTIC WELL�Z_0'tPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS X� <br /> Industrial Cable Tool Dia. of Well Excavation 44-- <br /> Domestic/private <br /> ZDomestic/private Drilled Dia. of Well Casing _4�5& <br /> Domestic/public Driven Gauge of Casing 2- <br /> Irrigation TGravel Pack Depth of Grout Sea �1 m <br /> Cathodic Protection �— Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface/Seal Installed By: m <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done Or <br /> PUNP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 F4R A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO / <br /> SIGNED <br /> PLO ON REVERSE SIDE) <br /> PHASE I FOR DEP MENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE S <br /> ADDITIONAL COMMENTS: <br /> PIWE,XI XOUT INSPECTION P /FINAL INSPECTION p <br /> INSPECTION BY DATE / INSPECTION BY No&= DATE -Z4 <br /> _E_H 1426 Rev. - <br /> . 74 0/77 2M <br />