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1!4 -­_. /�r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79- 3 91 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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. 1862 and- 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (,? CENSUS TRACT <br /> Owner's Name /' �l?h 'e ( .- <br /> Address <br /> City . r <br /> Contractor's Name ., { 1; _ <br /> License <br /> A <br /> % _ 32= a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION X PUMP REPAIR PUMP REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Gam ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY 'LINE - PRIVA'TE DOMESTIC WELL PUBLIC bOMESTIC WELL G <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 <br /> Gauge of Casing <br /> Irrigation i - r Gravel. Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br />—Geophysical 'e'er -y Sur;face:Seal" Installed By <br /> PUMP INSTALLATION: i Contractor - <br /> Type of Pump L' ,44.P, <br /> SMe <br /> PUMP REPLACEMENT: L/ State Work,Done X <br /> PUMP '.REPAIR: k D n4dw4a mcw OE-1-of <br /> e ' <br /> DES•TRUCfiION_OF WELL: _11_Wel3 Diameter pproximat Dap <br /> Describe Material and Procedure r <br /> s t <br /> I hereby agree to comply with all laws acid 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 j <br /> WELL DRILLERS REPORT of the well. and notifythem before i <br /> putting the-:well in use. The above <br /> information is true to the best of my knowledge and. belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO ROUTING FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> j <br /> APPLICATION ACCEPTED BY DATE 4�—r _ '2­0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �n. 13 DATE S - Z `Z- 17 <br /> E H 1426 Rev. 1-7L AX77 " ani <br />