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f � 3 <br /> 9 / SAN JOAQUIN LOCAL HEALTH DISTRICT, } <br /> FOR?OFFICE USE: VVV 1601 E. Hazelton Ave. , Stockton, -Calif. <br /> Telephone: (209) _466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-Z <br /> l � <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED,, Date Issue4_i "-�1_ <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. 186 nd the Rules and 'Regulations of the San Jon uin Local Health District. <br /> CA-d—"L-Tv/ f�, . " 2o,S 0(,6 --0� <br /> JOB ADDRESS/LOCATION �/ dile �.v aL-rTa �V j CCTT <br /> Owner's Nam C�Dom . - Phone fJ -'U <br /> Address 84 S l,o 1v <br /> . ,,._,._ ...,._, _....---• -.,...,__� City � <br /> Contractor's Name d-� _.�uy 1 jJ„--s � License t/Gn373 Phone d <br /> a <br /> TYPE OF WORK (Check): NEW WELL /=7 DEEPEN /_7 RECONDITION /7 DESTRUCTION /7 .. <br /> PUMP INSTALLATION / / PUMP REPAIR /77 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <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 <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: State Work <br /> nDon �,__-`;�07” <br /> �✓� �v '� c <br /> PUMP_.REPAIR: -74-_State-�-Work Done <br /> .l <br /> 2E&T RUCTION 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 ln.use.. The above <br /> information is true to the-best of- my knowledge and belief; I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r _ TITLE <br /> _(_DRAW PLOT_PLAN ON REVERSE SIDE) _FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L P1L,� q DATE <br /> ADDITIONAL COMMENTS: 4 z <br /> PHASE II GROUT INSPECTION S FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE �� <br /> i E H 1426 Rev. 1•-74 ' 1-74 2M <br />