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' .1L <br /> ' SAS JOA(tUIN LOCAL 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. 74- <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 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 Rules and Regulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION P 'Q, 1J_ 7elV CENSUS TRACT <br /> Owner's Name --- [LCA �`�(��� �` !y?7??fC /r Phone `%.4` 1171? <br /> ' Address 2 2 4/ City' <br /> Contractor's Name C'.I_ J)l h' License # 7GLbz Phone y4Z-u3 y� <br /> TYPE OF WORK (Check): NEW WELLDEEPEN/7 RECONDITION f7 DESTRUCTION Lf <br /> PUMP INET TION/ PUMP REPAIR 1-7PUMP REPLACEMENT <br /> Other L/ <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 WBLL CONSTRUCTION SPECIFICATIONS 9„ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal 5 <br /> Cathodic Protection Rotary Type of Grout Q <br /> Disposal Other Other Information 0 <br /> �oPhYs r �— 5 face Seal <br /> yI�nstalled -e p <br /> tit /o d <br /> PUMP INSTALLATION: ! Contractor • '/�o�f'/ \ / <br /> Type of Pump H.P. <br /> ' PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP �REPAIR: /7 State Work Done <br /> ' DES•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 /> 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 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 TOG UTING A FiNa INSPE=ION. <br /> SIGNED 1 ��, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE �- <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6 -2 7 <br /> ' ADDITIONAL COMMENTS, <br /> PHA% ' NSPECTION PH&SIOMIFIM INSPECTION <br /> INSPECTION BY DATE T��-% INSPECTION BY DATE <br /> E H 1426 R 1-74 ern/ �ruV/__ _�_ 4/75 2M <br />