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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave., ,Stockton, Calif. <br /> Telephone: _(209) 466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � THIS PERMIT_EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> A Et.7 (Complete In Triplicate) �,�-p�.. (4-'7=fLU-oS' <br /> Application is hereby made 't'o tie 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 Joaquidl <br /> County Ordinance No. 1862 nd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB + D S/LOCATION <br /> 'v r 7Rrli•- ,_CENSUS TRACT <br /> Owner's Name Hew Phone 3 <br /> Address , 0 . <br /> r c }�j_ City <br /> Contractor's Name r1( ICr�rL C License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN%/ RECONDITION /% DESTRUCTION /_7 � y <br /> PUMP INSTALLATION ,(wG'J PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> 9 ' <br /> DISTANCE TO NEAREST: ISEPTIC .TANK _ OEWER LINES a PIT PRIVY i <br /> SEWAGE-DI'S PQSAL FIEID - CESSPOOL`/SEEPAGE"PIT OTHER <br /> PROPERTY LINE..- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE -��, Yrhy TYPE. OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> A-' 'Cable Tool Dia. of Well Excavation- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing <br /> Irrigation it Gravel Pack Depth of Grout Seal C <br /> Cathodic Protection' Rotary � ` Type of Grout I <br /> Disposal w. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor i„ r ve <br /> Type of Pump XV IR 6 4P.4 H.P. . <br /> s <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMP .REPAIR: State Work Done FR j <br />)ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C 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 we11 'construction. tithin FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> Lnformation is true to the-best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND;A.F NAL,.INSPECTION, <br /> iIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />'RASE I 4i, <br /> ji <br /> IPPLICATION ACCEPTED BY. DATE <br /> LDDITIONAL COMMENTS: -=-- <br /> PHASE'� II:"GROUT INSPECTION PHASE III/FINAL INSPECTION <br />[NSPECTION BY DATE - INSPECTION BYDATE / <br /> w�. <br /> E H 1426 Rev, 1-74 ; 1177 2M <br />