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SAN JOAQUIN 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 /> 76 - 8a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> (Complete In Triplicate) <br /> Application is hereby made to the Scan Joaquin Local Health District for a permit to construct <br /> sand/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 �C, r � R / - ems a , CENSUS TRACT <br /> Owner's Name Phone <br /> Address City r <br /> Contractor's Name 40, U_XL License #A 132-3 Phoneme �- -�� <br /> TYPE OF WORK (Check): . NEW WELL.'/-7 DEEPEN '0 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTAL ION j / P REPAIR -��PUNP REPLACEMENT f T <br /> Other / / _ YJ -n . <br /> DISTANCE TO -NEAREST:- SEPTIC'TAN SEWER L S� - -P-1 PRIVY w <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Indi3strial �_ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /p <br /> Domestic/public Driven Gauge of Casing O <br /> _ X Irrigation Gravel Pack Depth of Grout Seal ------- <br /> Cathod1c Protection Rotaryf Grout _ �-- <br /> Dfsposa] �" Other Other Information€- - <br /> Geophysical Surface Seal Installed By: _. <br /> PUMP INSTAL lA.TION`: Contractor <br /> W Type of Pump ;..� H.P. <br /> PUMP REPLACE NT:-x? "' / % State Work Done k.. <br /> PUMP '.REPAIR: _A7 State Work Done <br /> ^ V � L• <br /> PES•TRUCTION 4F WELL: W 11 Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyiwith all laws and regulations of-the San Joaquin Local Health District <br /> and the State of Califorriia pertaining to or regulating wpil.. construc:tion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnisR-.-_the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of a well and notify them before tt_ing.the..wPl1 in .use... The above . <br /> information i true to t best of my.knowledge and beli -I,-WILL L FOR A GROUT INSPECTION <br /> RO <br /> PRIOR TO GN AND F AL INSPECTION. _ ' _ <br /> SIGNED TIT�LEr : <br /> RAW PLOT PLAN ON REVERSE SVD <br /> r FOR DEPARTMENT USE ONL - .,i=L:1 <br /> PHASE I <br /> APPLICATION ACCEPTED BYX I DATE ' 91 AL. ( <br /> ADDITIONAL COMMENTS: it F ° <br /> PHASE II GROUT-.INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION.., ('. DATE J i3 7� <br /> E H_1426 Rev. 1-74 ,. . <br /> L/75_ 2M_ <br />