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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrJOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i! Telephone: (209) 466-6781 <br /> it APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71--I/:V <br /> �M <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ? 9`7q- <br /> A. � (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to canstruct <br /> and/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDEDh 46R&qS/LOCATION � ' cENsus TRACT <br /> I�I ��'�- t ' Phoney�// � . <br /> Owner's Name <br /> Address I.` f.� ✓ .'� }/Y City- <br /> Contractor <br /> ityContract ra Name C �j (! / License �1'Phone <br /> -� <br /> MOM <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/-7 RECONDITION /7 'DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other 1 I <br /> DISTANCEITO NEAREST: SEPTIC TANK SEWER LINES y, 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 /> Industrial Cable Tool Dia. of Well Excavation .� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Iikgation 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: L/ State Work Done <br /> . . V4J <br /> PUMP`'REPAIR. - _ -State-work Done f <br /> ,RES'TRUCTION OF WELL: nWell Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereb � a agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Y,p. g P Y g <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 TONG OUTING AND A FINAL INSPECTION. <br /> SIGNED A4Na- _ TITLJi <br /> E <br /> I (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I1:r <br /> APPLICATION ACCEPTED BY DATE T <br /> ADDITIONAL COMMENTS: <br /> �M. PHASE II GROUT INSPECTION P FI AL INSPECTIPN <br /> INSPECTION BY DATE INSPECTION B DATE &12 �b <br /> '� <br /> 8 H 1, 426 Rev. 1-74 1-74 2M <br />