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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TO-BrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9'Zd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue, <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 Joaquin <br /> County Ordinance No. 1862 and the Mules and Regulat.o�nl h7 e San Joaquin Local Health District. <br /> JOB ADDREMS/LOCATION,=r-✓3,r/- N)e CENSUS TRACT <br /> 4 <br /> Owner's Name J� 91f'� ��� o �-�� Phone4Z63 �?7 <br /> Address ✓ Com[/ L 70 U 7- Citya <br /> Contractor's Name License J&�P373 Phone' � 6 <br /> TYPE OF WORK (Check): NEW WELL 'Iy DEEPEN/-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK c>C SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL o PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /0"" <br /> Domestic/private Drilled Dia. of Well Casi g 6 77 <br /> Domestic/public Driven Gauge of Casing 74 "4e-VIT�W, i QST i� <br /> Irrigation Gravel Pack Depth of Grout Seal_ -j6 ' r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -5 <br /> Type of Pump JF H.P. ' <br /> PUMP REPLACEMENT: State Work Don LU1 L <br /> 6• <br /> PUNS .REPAIR: -> -._ /7 State Work Done <br /> D_ES--TRUCTION OF WELL: Well Diameter � „-� Approxi to Depth <br /> Describe Material and Procedure r f r. GV C�Av <br /> I hereby agree to comply with all laws and regulations p Y gu ations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completio of my work on a new well, I will furnish the San, Joaquin Local Health District a <br /> WELL DRILL REP T of the a . notify them before putting-the- well in-use.. The above <br /> informati is e tr to the y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROU NG D A FI CTION <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE .III FINAL INSPECTION <br /> INSP39T=Ipli BY DATE INSPECTION BY (' : DATE 3 z <br /> E H 1426 Rev. 1-74 1-74 2M <br />