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,/ 5AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA('OFFICE USE: 1601 E. Hazelton Ave:, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z- 710 <br /> THIS PERMIT EXPIRES 1 •YEAR_ FROM DATE ISSUED Date Issued -7-j4-2,1 <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 is 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 4 S. ,duu, CENSUS TRACT az - 2Tv-39 <br /> Owner's Name 6, Phone <br /> Address _.. <br /> City cp�wr� <br /> Contractor's Name <br /> License Phone <br /> TYPE OF WORK (Check): NEW WELL /_ ~DEEPEN •/ RECONDITION /7 DESTRUCTION %j <br /> PUMP INSTALLATION PUMP REPAIR /-7—PUMP REPLACEMENT / <br /> 0 ther <br /> a <br /> DISTANCE JO,NEAREST: ,, SEPTIC'• TANK SEWER LINES PIT PRIVY <br /> "` SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE, STYPE 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 i Gravel Pack Depth of Grout Seal <br /> ? Cathodic Protection i Rotary Type of Grout <br /> Disposal [ Other __Oth!pi_Information, <br /> Geophys�i.cel �" -i Surface_Seal Installed By: - - <br /> PUMP INSTALLATION: Contractor ''a •' ^. <br /> Type iof Pump <br /> PUMP REPLACEMENT: State Work Done ^, <br /> 'PUMP :REPAIR �" <br /> • � - /. ""R'State Work--Done <br /> ES;TRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Describe Material and Procedure <br /> • f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California._�iertaining 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 GROU IN AND AL INSPECTION. <br /> SIGNED TITLE 57 <br /> i (DRAW PLOT LAN ON REVERSE SI <br /> AR <br /> PRASE I USE ONLY <br /> EAAPPLICATION ACCEPTS Y Q'r" DATE 2 -ZY zz <br /> ADDITIONAL COMMENTS: i - --- <br /> PHASE I GROUT INSPECTION PHASE I F NAL INSPECTI N <br /> INSPECTION BY410 <br /> DATE INSPECTION- BY /� . DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 9M^ 1° <br />