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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone 2 <br /> • (209) 466-6781 <br /> µ APPLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. <br /> w 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. 18 )/62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /­766 -s-,A u S {'V Al. /�/b t-/ I cw CENSUS TRACT <br /> Owner's Name Ta m Q -s 74 Choy -m w o Phone 23 'G 7 <br /> Address 176634 1 ( /� CQ� City //� �s� <br /> ALA <br /> Contractor's Name ,tUNI � License #7 <br /> &0 Phone([ 2 L�! <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /—/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 *J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ndustrial Cable Tool Dia, of Well Excavation t6 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ / _ <br /> Irrigation ravel Pack Depth of Grout Seal <br /> � <br /> Cathodic Protection - _ notary Type of Grout 4�e/yr l <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor o--r e b hl <br /> Type of Pump ;J ,? H.P. <br /> i-�S ) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> D7-0 <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth /y/ <br /> Describe Mad d Proo�dure 11 <br /> '—` <br /> 11� <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 ROUTING ANDA FI AL PECTION. <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 19//C�?2 <br /> PHASE I <br /> APPLICATION ACCEPTED BY "DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G-ROM INSPECTION PITASE"IIWFINA1, kNSPECZ16N <br /> INSPECTION BY DATE INSPECTION BYATE - .,?- 7 7 <br /> E H 1426 Rev- - 1-74 �� <br />