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J - Yom° SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEjOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z5'-7?,rJ <br /> Jr. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3.15x:.7 <br /> ` (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> I County Ordinance No. 1862 and the Rules and Regulations of the 'San Joaquin Local Health Districi. <br /> JOB ADDRESS/LOCATI N CENSUS TRACT 070--a, <br /> �¢ ` <br /> Owners Name µ <br /> � Phone <br /> Address City <br /> Contractor's Name License 9 Phone <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN -/7 RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION -PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other /% <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 WELL CONSTRUCTION SPECIFICATIONS <br /> F Industrial a Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 74Z m464* <br /> Domestic/public Driven Gauge of Casing <br /> ligation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR;! <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 /> j WELL DRILLERS REPORT of the well and notify them before putting the..well in.use.. The above <br /> information is true to thembest of my knowledge and belief. I WILL CALL FOR AmGROUT INSPECTION <br /> PRIOR TO GROUT;VG D A FINAL I CTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE V� <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE III FINAL INSPECTION <br /> a <br /> INSPECTION BY 04VDATE INSPECTION BY DATE <br /> OD <br /> + E H 3.425 Rev. I-741-74 2M <br /> M <br />