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LS/ SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71,A- 3 f9lJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) = . . <br /> Application is hereby made to the San Joaquin Local Health. Diatrict. for- a permit to construct <br /> and/or install the work herein described. This application ,is made incompliance with San,Joaquin <br /> County Ordinance No. 1862 and the Rtiles-,and Regulations of the—San—Joaquin—Local Health- District. <br /> - . <br /> 30B ADDRESS/LOCATION ;.L CENSUS TRACT V. ; <br /> Owner P s Name ' µ Phoneme F--Z0,5_ <br /> .9 <br /> Address ,�f ,- _ ..._. _ <br /> �`.4 Cit :d/ <br /> Contractor's Name �oE — O <br /> a <br /> License #a?5-S'F,77 Phone <br /> TYPE OF WORK (Check): NEW WELL -Iff DEEP I—T CONDITION /? DESTRUCTION-/_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT `' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S (CESSPOOL/.SEEPAGE PJY OTHER <br /> PROPERTY LINE 2 PRIVATE DOMESTIC WELL` PUBLIC'D'OMESTTC. WeL= N_� <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICAPIONS, <br /> Industrial ! Cable Tool Dia. of Well Excavation or T7 <br /> _ Domestic/private I Drilled Dia. of Well,�asing t, 7. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of-Grout Seal S , `. <br /> —„_ Cathodic Protection ► Rotary Type .of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �- H.P. <br /> .' <br /> PUMP REPLACEMENT: State-Work Done + 'K �. it <br /> -, .. - <br /> PUI� .REPAIR: T L� `State'Work Done <br /> ES.'TRUCTION OF WELL: Well Diameter Approximate Depth:. <br /> PA P <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.willwfu.mish the San Joaquin Local.Health District a <br /> WELL DRILLERS REPORT 6f -the well and notify them before putting.-the.-well in.use.. The above <br /> information is true tij the -best :of. my 'knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T U NG D NAL; INSPECTION;, <br /> SIGNE � TITLE <br /> (DRAW``PLOT PLAN ON REVERSE SIDE <br /> -i. <br /> G F'OR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACC ,TED B = DATE <br /> ADDITIONAL COM[+DJI(w ;' <br /> PHASE"((; GROUT INSPECTION PHASE III FINAL INSPECTION <br /> :INSPECTION BY -,DATE ,17- 7 <br /> INSPECTION BY DATE °- <br /> f R H 1426 Rev. y <br /> 1-74 1-74 2M <br />