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Cd m. A t/A ef � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA OFF CI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .741-339 <br /> " THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?7� <br /> (Complete In Triplicate) <br /> Application is ereby 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 - a-.4X' VgC AILI& s je, �:irrL tU CENSUS TRACT <br /> Owner's Name nG dc �a .r T Phone <br /> Address 34 Q. 0 S i r d2 a Gt.1 City S-/, LOA <br /> Contractor's Name v / w a License # 4.4 2 LJ-Phone �� -.7,4 W <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR X-7 PUMP REPLACEMENT /7 <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 <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 . R.P. 43 4 <br /> PUMP REPLACEMENT: /7 State Work Done <br /> . R <br /> PUMP :REPAIR: Y7 State Work Done k ,Q p ° e,0*614ed n n, <br /> 3,REES,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 thewell in use.. The above <br /> information is true to the best of my k ed d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AIJD A FINAL E N <br /> SIGNED ,. <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE./III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION $Y DATE ^Z_ -�� <br /> E H 1426 Rev. 1-74 1-74 2M <br />