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SAN JOAQUIN LOL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 741.-" hJ ; <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB S/LOCATION �� ; !�+ �p yy ; &SUS TRACT <br /> Owner's Name l/(jQg ds- �,�iLtp �l� Phone <br /> Address City <br /> Contractor's Name License n�APhone <br /> I <br /> s <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN/7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / J PUMP REPAIR /7 PUMP REPLAC 17 t <br /> t Other <br /> S . <br /> I <br /> ,DISTANCE TO NEAREST: SEPTIC TANK ® SEWER LIVES PIT PRIVY/49 4 j <br /> SEWAGE DISPOSAL FIELD/ CESSPOOL/SEEPAGE PIT/ /JOL OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL kUBLIC DOMESTIC WELL <br /> •' ' INTENDED USE TYPE OF WELL — CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> r Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _P7 Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information Q <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'.REPAIR: /-7 State Work Done <br /> 2ES-TRUCTION OF WELL: Well Diameter 1 Appr xi.mate Depth <br /> - Describe Material and Procedure <br /> 14 jr <br /> t�U <br /> I hereby agree .to comply with all laws and egulations of the San Joaquin Local Health Distfict <br /> and the State. of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of any work on anew 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 GROUTING AND A FINAL INSPECT f <br /> SIGNE -lmhlnD ,TLE A <br /> PLOT PLAN ON REVERSE SIDE <br /> # R DEPAR MgNT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ,B f� DATE %%//may/ 7_%_ <br /> ADDITIONAL COMMENTS:( <br /> PHASE II GROUT INSPECTION PHASE 1114gINPjo INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY DATE <br /> IF <br /> 411617/=ylo%'Z9rxr <br /> E n 1426 Rev. I-74 - <br /> r.— <br />