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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, ,Calif. <br /> t 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 �-7ft-j6 <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 79fC 7, T/5 I? `7 f CENSUS TRACE <br /> Owner's Namerr� fun��k // � sem/ Phone <br /> Address / `1629 �r. eLu.nscf �cl City" / c1 <br /> Contractor's Name 2//meq License # '7664)Z Phone yLL- 3/7 <br /> ! <br /> TYPE OF 'WORR (Check): NEW WELL X DEEPEN/7 RECONDITION TT DESTRUCTION /7 <br /> � . PUMP INSTALLATION/ / PUMP REPAIR/� PiJMP REPLACEMENT f <br /> ti Other <br /> DISTANCE TO NEAREST: SEPTICjTANR 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 .1--y Cable Tool' ' Dia. of Well Excavation <br /> :. Dome a tic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing L577 <br /> Irrigation = Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout " <br /> Disposal i Other Other Information" <br /> Geophysical Surface Seal Installed By. " <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PL24P REPLACEMENT: . F' / / State Work Done <br /> PUMP .REPAIR: /: / ,State Work Done <br /> DESTRUCTION OF-WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 . <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 weli. in.use.._ The above <br /> information is true to the beat of" my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION . <br /> PRIOR TO MUTI G A FINAL.INSPECTION. <br /> SIGNED _ TITLE � �i/� l ✓ <br /> 7 (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> jffT71-cKTiON ACCEPTED BY DATE -/ -76 <br /> MW rIONAL COMMENTS: D � <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY / DATE INSPECTION BY DATE / <br /> E H 1426 Rev. 1-74 6/vk 0u., <br />