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1,� S JOAQUIN LOCAL HEALTH DISTRICT PO <br /> EOE OFFICE USE: 1601x. Hazelton Ave. , Stockton, Cali3. <br /> p Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 <br /> '/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a -_L#- <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION /f 6�� S- �!/ ,& -'� J /� CENSUS TRAyACT <br /> 67 <br /> wner's Name / v�/^ < /(=/J�j �'� CJiPhone / ,C/ � 11" <br /> d d r e s s ✓ -� S / / � �t CCity fZ/ / Cj <br /> ontractor's Nam:, �r d� � License J10,1Z 7'-'�honeT�4 9r <br /> -YPE OF WORK (Check) ; NEW WELL. IV DEEPEN%/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> r <br /> ISTANCE TO NEAREST: SEPTLC TANK EWER LINES770 PIT PRIVY <br /> SEWAGE DISPOSAL YIELD CESSPOOL/SEEP PIT OTAER <br /> PROPERTY LIN RIVATE DOMESTIC WELL,,) PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI TS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing _ U <br /> _ Irrigation `/ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t/ Rotary Type of Grout <br /> Disposal Other Other Information /3t� <br /> _Geophysical Surface Seal Installed By: <br /> ,UMP INSTALLATION: Contractor <br /> Type of Pum_P7 H.P. <br /> \\ <br /> UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR; / / State Work Done <br /> )ES"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 /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL 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 /> 'RIOR TO GRQUTING AND A FINAL INSPECTION. <br /> SIGNED u TITLE i <br /> DRAW PLOY PLAN ON REVERSE SIDE <br /> DEP MENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEP B SIVAgL DATE Z " 22 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. DATE <br /> E B 1426 Bev. 1-74 /,e las4"2,/) <br />