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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: L / 1601 E. Hazelton Ave. , Stockton, Calif, <br /> �V/ 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 L.�7d <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 Y W amu/e' ENSUS TRACT <br /> Owner Is Name �6'Y 63 / ._ <br /> S ✓� Phone � <br /> Address 74 w cA S r City <br /> Contractor's Name -.� /� .. �P �a License #74 Z Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN /_7 RECONDITION T DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR 1_7 PUMP REPLACEMENT /J <br /> Other /_1 <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 U <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 77a- <br /> Domestic/public Driven Gauge of Casing V� <br /> Irrigation Gravel. Pack Depth of Grout Seal C� <br /> S <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> -Geophysical �� <br /> Surface Seal Installed„By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /State Work Do e <br /> PMREPAIR: /7 State Work 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR I`0 NG D FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> -- R DEPARTMENT USE ONLY <br /> PHASE I �✓ <br /> APPLICATION ACCEPTED 'BY DATE 3/ 7✓ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> 4 E H 1426 Rev. 1-74 <br /> 1-74 2M <br />