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7A/4 L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT M.41 'L A 70 49"11V�61` <br /> FOk 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 /� <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 G��,sT Srlae McA14w e � . <br /> of ��N�s. CENSUS TRACT <br /> Owner's Name Y A40AI0 ' rl !�� __,..., Phone <br /> IAj <br /> Address r- 4 �&j 6q_t_1j�t��City <br /> r � <br /> Contractor's Name :5 TAW I (,P\--J S' J kA icense # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/% RECONDITION /_/ DESTRUCTION /_7 <br /> i <br /> PUMP INSTALLATION E-PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> 04111 Other — <br /> �/ <br /> D STANCE 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 „� �-- L06cll/%2 <br /> Type of Pump — H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Ione <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 ''r <br /> and the State. of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after compleion 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 GROUTING AND AAFINkL I PECTION. <br /> SIGNEj2V TITLE' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE (7-7r <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASEAI,9INSPECTION <br /> INSPECTION BY DATE �� INSPECTION BY ATE <br /> E H 1426 Rev- 1-74 $97 _ 2M <br />