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SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> FOE OFFI USE: dj/601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: .-(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_ipa fro <br /> THIS PERMIT EXPIRES I 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 L cal Health District. <br /> JOB ADDRESS/LOCATION _ i S V _orL CENSUS TRACT <br /> Owner's Name LSY`4"dwlw X-9 49P/'1 Phone <br /> f � F <br /> Address _Z) / e �. - - - --- Citya,�.�O r <br /> Contractor's Name �� Liicense #/ <br /> P,41,1-1-hone <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / /+ RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION`:/ / "PUMP REPAIR / / <br /> PUMP REPLACEMENT / 7 <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> x Domestic/private Drilled Dia. of Well Casing (n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout' Seal <br /> Cathodic Protection : .. Rotary Type ,of Grout <br /> )Aspos,Z Other y Other Information <br /> Geophysical L Surface Sear Installed--By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s^ H.P. <br /> PUMP REPLACEMENT: /mac/ State Work Done3 <br /> PUMP .REPAIR: / / State Work-.Done <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 <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 be-l-efe. I .jWILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G I G AND A FINAL INSPECTIO . <br /> SIGNED ,r J a- S . <br /> W :P T P AN N RE ERS SIDE) :,. . 7 l <br /> } F R EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ;. DATE Zp K <br /> ADDITIONAL COMMENTS: <br /> PHASE II ChUSPECTION PHASE ITT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 2 DATE /p- "7,6 <br /> 376 <br /> E H 1426 Rev. 1-74 "2M <br />