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`fCl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-34/4J <br /> .�s=3s Ila <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-Q?aZ 7S <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. J <br /> JOB ADDRESS/LOCATION i CENSUS TRACT <br /> " <br /> Owner's Name �G�.c 4L� �. Phone �� �.,. 3S- <br /> Address S-AddressCity - - <br /> Contractor's Name _ USC. License #1 2373 Phone _ <br /> TYPE OF WORK (Check) : NEW WELL jo' DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION er PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other /-7 <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 X Cable Tool Dia. of Well Excavation _7 <br /> —) Domestic/private Drilled Dia. of Well Casing g <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. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: <br /> State Worki Done _ <br /> ES•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 /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the best ofmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO AUING ANA FINAL TNSPECTION. <br /> SIGNED TITLE <br /> T;t7DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G11/P DATE �:•�/- J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI2P PHASE III FINAL INSPECTION <br /> INSPECTION BY ,` , DATE INSPECTION BY f- DATE <br /> E H 1426 Rev. ]-7 4 <br /> 1-74 2M <br />