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1'0ju SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi:_O VICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 3 Telephone:. (209) 466-6781 <br /> -A 2M APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 76 <br /> -+ (Complete In Triplicate) . "J- IDZ�&--VI&- �f <br /> Application is hereby made to the Sat: Joaquin Local health District for a perriit 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 .4� 41e, d w CENSUS TRACT <br /> Owner's Flame � i•G.! ����c r�� Phone , <br /> F <br /> .r <br /> Address �d ��--� 1114-ir 4e op, City . . 1 <br /> Contractor's Name �4d 0,0// License #/yj 71-_�Phone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN -/_7_�RECONDITION f7 DESTRUCTION /_ <br /> PUMP INSTALLATION "/_/ PUMP REPAIR/7 PUMP REPLACEMENT jg <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY K,�1 <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 /> Geophysical Surface Seal Installed By: { <br /> PUMP INSTALLATION: Contractor G �c <br /> Type of Pump /a.,�r r H.P. / } <br /> PUMP REPLACEMENT: /x/ State Work Done A <br /> P <br /> PUMP ,REPAIR: 1-7 -State Work Done 1 <br /> DES•TRUCTION ,OF WELL: Well Diameter Approximate Depth <br /> - --- Describe Material and Procedure !I <br /> _ 4 <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.... .The above <br /> information is true to the-beat of .my-�. xo'ledge,and belief. I WILL CALL FOR 'A 'GROUT INSPECTION <br />, PRIOR TO POUTZNG`AND A FINAL INSPE ON. <br /> SIGNED ITLE " <br />'k D W OT PLAN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br />` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F AL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> If E H 1426 Rav_ 7..71a U77 <br />