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- �0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOII OFFICE USE: .1601 E. Hazelton 'Ave: '; Stockton, Calif. <br /> Telephone: - `(209) 466-6761 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUPtP PERMIT Permit No. 7�/- <br /> THIS PERMIT-EXPIRES l.YEAR FROM•DATE ISSUED Date Issued 7-9 Z <br /> (Complete In _Triplitate). " <br /> Application is hereby made to the San Joaquin'Local7,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. qa 3 CENSUS TRACT - <br /> Owner's Name .&LSele R&LL 0-.:..,: . ..-- - Phone g -?$6 0 <br /> Address. _. j� y �� J i _..... ,-. City 4tSc&Lonj <br /> Contractor's Name . 7 License p Phone <br /> .- <br /> TYPE OV ORK _(.Check)_:NEW;WELL /- DEEPEN '/-7 RECONDITION /7 DESTRUCTION <br /> PUMP-INSTALLATION / / PUMP REPAIR a' PUMP REPLACEMENT_TY <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLINES PIT PRIVY <br /> ~' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT 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 6f._Grout' <br /> 7 <br /> Disposal Other_ Other_,In€ormation <br /> Geophysics -�" ` ' Surface Seal~ Installed B <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump + crw H.P. <br /> ti <br /> PUMP REPLACEMENT: %/ State Work Done. <br /> I� PUMP :REPAIR: ` State Work Done-:a <br /> ,DES.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 neva well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT'o.f 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 GROUT ING AND A FINAL OSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE $I <br /> FOR DEPARTMENT USE ONLY ^` <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />� ADDITIONAL COMMENTS. <br />` PHASE II GROUT INSPECTION PHASf, NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY WeLe!r DATE 7S^� <br /> i E H`"1426 Rev. 1-74 1-74 2M <br />