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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71" S2�i:` <br /> r <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 o9jiv/jz J • CENSUS TRACT <br /> Owner's Name (" I L A P P Phone <br /> Address t City es .. j DIV <br /> Contractor's Name ,,;'ry`. �} , , License _,272DJU?hone 43y,- <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /% RECONDITION /-7 DESTRUCTION /—] <br /> 71 <br /> PUMP INSTALLATION / / PUMP REPAIR /. PUMP REPLACEMENT /? <br /> Other/ / <br /> DISTANC TO NEAREST: SEPTIC TANK SEWER L'1NE9 <br /> PIT-PRIVY <br /> w� SEWAGE DISPOSAL-FIELD, 'i`'` ' CESSPOOL-•-S-EEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC 'WELL- - P'i�C DOMESTIC WELL <br /> INTENDED.USE TYPE OF WELL-_ CONSTRUCTION SPECIFICATIONS <br /> Industrial ( r Cable" ToolDia. `of Well Excavation �► <br /> Domestic:/private !Drilled Dia. ;0fCasing <br /> Domestic/public, ;Driven Gauge of Casing <br /> irrigation `:,P Gravel Pack Deptfi of Grout Seal 4 <br /> Cathodic'; Protection !Rotax_y -, _T_ype `of Grout �7 <br /> -Disposal-,­ Other Other Information <br /> Geophysal Suface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: 1.`"/ / -State Work Done <br /> .. <br /> PUMP .REPAIR: � `TSt&fe Wo k Done <br /> P <br /> DESTRUCT14. OF'WEIZ: ' Well �i'ameteF Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with` 'all laws and regulations of the -Sdti Joatluin`Lo'ca1 -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 we11 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`, , XNAL` INSPECTION. <br /> SIGNED TITLE , t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT .USE ONLY f <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i / <br /> PHASE, II GROUT INSPECTION PHAS.V IIIA/FINAL INSPECTIO <br /> . INSPECTION BY & ;i., DATE INSPECTION BY 414#�-lj DATE .. <br /> E H 1426 Rev. 1--74 t 1 177 2M 1 <br />