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( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � ;`" FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ( I <br /> Telephone : (209) , 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, -373Le <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 �Meoe— �r �r� j� CENSUS TRACT <br /> Owner's Name IFv%LI <br /> Phone <br /> Address lj /YL r <br /> city <br /> ,76 <br /> Contractor's Name ( • JA. License 1/1 .2 .2Q1r_Phoneh ,2,2_ <br /> i <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN /_% RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_ <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 /> Industrial �� Cable Tool Dia. of Well Excavation L% <br /> &/- Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing \n <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary P Type of Grout, <br /> Disposaq Other Other Information 42a4 0/ .4 <br /> Geophysical 7� /Surface Seal Installed B : � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump yr, H.P. <br /> • ti , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP °.REPAIR: / / State Work Done <br /> DESTRUCTION 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 TO G OUTING FINAL I S - CT ION. <br /> SIGNED TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE r `� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B �; DATE <br /> ADDITIONAL COMME T ' <br /> P T INSPECTION P I/F NAL INSPECTION <br /> INSPECTION BY / DATE _ INSPECTION BY DATE 75 <br /> E H 14261 Rev. 1-74 <br /> 1177 214 <br />