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JXul JUAqul" LukAL titALlli 1115'1Kll:'1' <br /> E OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: "T209)' 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d 3 <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 JoAquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION SD l6 fA S 7 f fly&611 6A M P IIT CENSUS TRACT <br /> Owner's Name l? ,,y 61?16 Phone <br /> Address _ �SyS 7__1.0N ✓9 y- City 5TOG4'7aA/ o <br /> Contractor's Name if 1A R/r W C,11 f f 4 U/p, GO License # %,",Z Phone _Sf <br /> TYPE OF WORK (Check) : NEW WELL ST DEEPEN /_7 RECONDITION /_ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR.,L-7 PUMP REPLACEMENT /7 <br /> Other <br /> ... <br /> DISTANCE TO NEAREST: SEPTIC YANK , 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 CONSTRUCTIONiSPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ` �7 <br /> Irrigation Gravel Pack Depth of Grout Seol <br /> Cathodic Protection ? " Rotary Type of Grout E*70117-4 <br /> Disposal LSOther Other', Informationl, <br /> Geophysical Surface Seal Instilled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / `State Work Done <br /> PUMP ,.REPAIR: /_7 State Work Done <br /> LDES.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 DR LERS REPORT of t well and notify them before putting the well in use. The above <br /> informs i is true toMNJ <br /> st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />�RIOR ING AINSPECTION. <br /> ESIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT UStONLY <br /> CHASE I <br /> APPLICATION ACCEPTED BY DATE <br />■ADDITIONAL COMMENTS: (/ <br /> PHASE II GROUT INSPECTION V PHASE III4FINAL INSPECTION <br /> E�NSPECTION BY 7r` DATE -INSPECTION BY DATE .6 <br /> E H 1426 Rev. 1-74 1177 - pM <br />