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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7-6 364,) <br /> ! 7T-Ad71° <br /> TH.IS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ �] <br /> (Complete In Triplicate) <br /> Application is hereby made t�o 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. 18.6.2-and-the--Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS ,GA ION CENSUS TRACT <br /> Owner' <br /> fN me Phone?- .31 " <br /> Address `73 <br /> City r <br /> Contractor's Name Qmolutom�1 � _,_____.,_.—_ License / 7- hone <br /> ._TYPE O.F_WORK. (,Check).: :.,NEW WELL_ EDEN RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALMATION /LUMP REPAIR / / PUMP REPLACEMENT <br /> I 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 ITYPE OF WELL CONSTRUCTION SPECT CATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4--175-me s tic/private I Drilled Dia, of Well Casing N <br /> Domestic/public Io-1 Driven Gauge of Casing <br /> Irrigation { Gravel Pack Depth of Grout -Se-al <br /> Cathodic Protection � x---Itotary Type of Grout <br /> Disposal I Other Other Information a' <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor M-Usz�l <br /> Type of PumpH.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> F PUMP .REPAIR: / / State Work Done, <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � I hereby agree to comply with all .laws and regulations of the Sari 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1/� <br /> APPLICATION ACCEPTED BY DATE �` -T <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_ III/FINAL INSPECTION <br /> INSPECTION BY - - -- DATE INSPECTION BY ��r� DATE �/- p r• ' ' <br /> 1177: <br /> E H,_1426 Rev. 1-74 ; - 2M <br />