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Co la SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 751_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued le- 70 <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/LOCATIONAL/e) n l.' 2 7ko(' CENSUS TRACT <br /> Owner's Name 7 e nv Phone <br /> Address /� W leo .n h�ec� ✓i City �� dE< <br /> Contractor's Na vr� � `�" � License # tyy zyhone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /"j <br /> PUMP INSTALLATION / / PUMP REPAIR fi PUMP REPLACEMENT /7 <br /> Other 1-7 <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 �I <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor mtea A,r . <br /> Type of Pump ,r-d I V2 '. 10 H.P. CJ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: X-7 State Work Done C It ae Vo IV-e 4-z, 60 OV-dO y ,, <br />,RES-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- veli in use.. The above <br /> information is true to the best of my kno leda ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FI_ML INSP ION <br /> SIGNED ! ITLE <br /> (D T' ON SE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /0-/s-7y <br /> E H 1426 Rev. 1-74 1-74 2M <br />