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' b"I SAA? JOAOIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k'�� <br /> Com lete In <br /> ( p 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 /> E JOB ADDRESS/LOCATION P 'j J/_ Za , CENSUS TRACT <br /> Owner's Name <br /> J A <br /> S 1 Phone <br /> Address 2 9 /4 City � C� <br /> Contractor's Name / Il-> eO, License # Phone //4Z- <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/7 RECONDITION %f DESTRUCTION f7 <br /> t PUMP INST TION/ / PUMP REPAIR I 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 /> a INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private DrilledDia. of Well CasingIN <br /> Domestic/public Driven Gauge of Casing 77 NA <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information i <br /> Geophys T� Su face Seal Installed -r' <br /> r11 ��. L <br /> i' PUMP INSTALLATION: Contractor �0'f'1h pa <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMPREPAIR: /-7 State Work Done <br /> bES�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-of- my..knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO GROUTINQAND, A PI44 TNSP ION. <br /> SIGNED .01 <br /> TITLE <br /> {DRA PLOT PLAN ON REVERSE SIDE <br /> FOR.-DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMHENTS: <br /> PHAS NSPECTION P INSPECTION <br /> INSPECTION BY DATE _� INSPECTION BY DATE <br /> �vr�{H9 u . 4175 2M <br /> E H 1426 R 1-74 � rr <br />