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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: !/ 1b01 E. Hazelton Ave,-,' .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7�2 3o,P <br /> THIS PERMIT EXPIRES l YEAVFROM DATE ISSUED Date Issued a2Z�7 7 <br /> (Complete 1n. Triplicate) <br /> Application is hereby made to the San Joaquin Local.41ealth District for a pert 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 :: /c?/'7 S'i SA CENSUS TRACT <br /> Owner r s Name )V O. Phone $3$-Q?IR <br /> Address.' M 5 City �SCl9Lo r✓ <br /> Contractor's Name 'x,D.. ""per a,v License #4ojo Phone 85$,z�o"7 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR'./ / PUMP REPLACEMENT <br /> Other /J <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 I <br /> Type of.;Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> l PUMP !'REPAIR;. f�" State Work Done <br /> X&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 /> Y and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i after completion of my work on a new well,,V,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 GRO -TING AND A FINAL INSPECTION, <br /> fSIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i - FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _: DATE !� <br /> ADDITIONAL COMMENTS: <br /> F <br /> PHASE II SEZT INSPECTION PFIASF� II/ , N INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Iry <br /> E H 1426 Rev. 1-74 1-74 2M <br />