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( G rt C 40 04��� _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08 OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75_ 2-i� <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IV �-�y ,. CENSUS TRACT <br /> Owner P s Name � �_S /�r' r S Phone <br /> Address / ✓ • a r�n � City d SAW, <br /> Contractor's Name .0// License s' '7.,j Phone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR 1-7-pump REPLACEMENT /? <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 4GA6 JV2 6 OtXi H.P. <br /> / <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP State Work Done / - 6r✓ -Y.--1.. ��► �1/e� ��, ! <br /> j&S-TRU` CTION 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 led and b ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL :1NSggCTWr,-- <br /> SI ED !AWA TITLE ' <br /> (DR4ffl PLOT FLff4OdN64WSE SIDE <br /> R D ARTMENT USE ONLY <br /> PHASE I ,� r 7 r <br /> APPLICATION ACCEPTED BY 0.x.4 DATE / j <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r - „ DATE <br /> C� <br /> ' E H 1426 Rev. 1-74 1-74 2M <br />