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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO rOFFiCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �✓ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 342/ j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> � (Complete In Triplicate) O t 7 - 050- 07 <br /> Application is hereby made to the San Joaquin .Local Health district for a permit to construct <br /> and/or install the worm 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 / M/ dkCENSUS TRACT <br /> Owner's Name .Smog _ y��" Phong3g <br /> Address vl 4 ef_ City t <br /> Contractor's Name jGcn License # Phone _79 <br /> TYPE OF WORK (Check): NEW WELL `DEEPEN /� RECONDITION /� DESTRUCTION (7 <br /> PUMP INT LATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /_7 / <br /> r. <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 <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> t Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal = •: 3 <br /> Cathodic Protection Rotary Type of Grout <br /> : Disposal Other Other Information <br /> Geophysical Surface Seal Installed$Y:`moi <br /> r PUMP INSTALLATION., ContractorOgg: <br /> s Type of Pump T i G H.P. <br /> PUMP REPLACEMENT: - - <br /> State Work Done <br /> PUMP `.REPAIR: �'/-7 State Woxk Done' j <br /> �T k <br /> ,RES 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 DRILLERS REPORT of the well and notify them before putting the.-well in-use.. I The above <br /> information is true to the best-of- my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GBOUTI19G AND A FINAL INSPECTION. <br /> SIGNED TITLE C.F,dQ7 .e, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> 'E H 1426 Rev. 1--74 1-74 2M <br />