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SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> FOF- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 "6 3 <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 /> Fits; G• e- 0,4C E-41 <br /> JOB ADDRESS/LOCATION (7R0,ra.j Co 4--ve-7. CENSUS TRACT Z30-1 z <br /> Owner's Name R u AAJ 0 Phone 3(g G410 <br /> Address L.2'-t. iV f.A r2 t /7ve City L-o o i <br /> Jull 44 <br /> Contractor's Name (Division of San Japquin Saiphur Co) License # .?1,0376 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / DESTRUCTION /-7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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: i-1 State Work Done <br /> PUMP .REPAIR: /tate Work Done e-W <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 CaCC gOR A GROUT INSPECTION <br /> PRIOR TO ANDA F NAL INSP= ivoquin rump -01 <br /> SIGNED TITLE (Division of San Joaquin suia.iu <br /> (DRAW PLOT PLAN ON REVERSE SIDE) cr,�r t• <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .•- <br /> ADDITIONAL, COMMENTS: 27 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D11`TE <br /> E H 1426 Rev. - 1-74 b/77 2M <br />