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Jutillukii Luk," 11L'tli ill U1J1K1Gi <br /> FOR OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (i09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7-QlU <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> end/or install the work herein described. This application is made in compliance with San Joaquin <br /> lounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LIfN``►� ►- t 4e CENSUS TRACT <br /> Owner's Name �pv Q �'i Phone <br />.ddress 11' EF S City <br />:ontractor's License # �J Phone y- 6 <br /> i <br />'YPE OF WORK (Check) : NEW WELL L-7 DEEPEN /-7 RECONDITION /-J DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT /7 <br /> Other <br /> aISTANCE 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br />-,�- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> — Disposal Other Other Information <br />-t Geophysical Surface Seal Installed By: <br /> Rdl!_INSTALLATION: Contractor <br /> Type of Pump ,S H.P. / <br /> 1UMP REPLACEMENT: / / State Work Done <br />-JMP .REPAIR: / State Work Done <br /> LSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> red the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> CLL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> reformation is true to the best of my knowle : Zef. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GR N AND A F NAL INSPE / <br /> GNED CTLE <br /> DRAW PIT ON REV SE SIDE <br /> DEPARTMENT USE ONLY <br />_ASE I 'A <br /> PLICATION ACCEPTED BY DATE /` 7 <br />-DITIONAL COMMENTS: <br /> PHASE II OUT IN ECTION PHASE III FINAL INSPECTIOLt <br />-SPECTION BY DATE INP.ECTION BY OleDATE 7 <br /> E 14426 Rev. 1-74 <br /> 1177 2M <br />