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SAN JOAQUIN LOCAL HEALTH DISTRICT �( d <br /> FORLURCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7///�7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued La3L77 <br /> (Complete In Triplicate) Oil -- 11?0—pry <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const uct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the Saxe Jo cquin Local Health District. <br /> .�T!!(: ';CL) .. E`'rr <br /> JOB ADDRESS/LOCATION © L✓1 A> a,42 QZ,2p l CENSUS TRACT <br /> Owner's Name / z Phone _ <br /> Address 1r I t1 f. o� D �G Q City <br /> Contractor's Name .. ,,, License #A-3 71.J7Phone C � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/% RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LTNE - 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 /> Y 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 �7CIA/ <br /> Type of Pump ul H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done r m :2/0 ' <br /> we- <br /> DESTRUCTION 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 now dg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I S C N <br /> SIGNE ��'" TITLE <br /> PL T PLAN ON ERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE g� 3--Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 ,x%7 _ 2M ' <br />