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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: II 1601 E. Hazelton Ave. ,' Stockton, Calif. 1 ,' l- T"?' <br /> u Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f---IYO <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) / /, - ...jf4`r !- <br /> Application is hereby made to the San Joaquin Local Health District for a Ptrmit to construct <br />° and/or install the work.h: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 aMA <br /> i� CA a s sa Phone <br /> Address `� 0 m.e. `+i ' City !CZdc t7_0 / <br /> U , _ i <br /> - <br /> Contractor's Name QA v''•O /A,4C License #;?45- ," Phone <br /> _ _ <br /> TYPE OF WORK (Check) : .NEW WELL / f DEEPEN '/ / RECONDITION �/ DES.TRUCTION_,~/���� <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> ,L/—PUMP REPLACEMENT,,N/A-Oiher <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK / Q SEWER LINES PIT PRIVY <br /> - SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 14) ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> .,INTENDED USE ... TYPE OF WELL CONSTRUCTION SPECIFICATIONS `^ i <br /> Industrial i; Cable Tool Dia, of Well ..Excavation <br /> Domesticfprivate Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i---Irrigation Gravel Pack Depth ,of Grout Seal _ t <br /> Cathodic Protection Rotary Type of- Grout _ <br /> Disposal Other Other Information <br /> Geophysical i Surface'Seal Installed By: <br /> 7 . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -. H.P. f <br /> PUMP REPLACEMENT: t <br /> . /� State Work Done�a,���2� <br /> ii <br /> PUMP .REPAIR: /77 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter , Approximate Depth r <br /> Describe Material and Procedure - — <br /> I hereby agree to complyhwith 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 puttingthe- 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 /> PRIOR TO GROUTING ,.4ND A FINAL INSPECTION. <br /> SIGNED <br /> oel <br /> TITLE <br /> (DRAW-,PLOT PLAN ON 'REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE -� g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II/F NAL INSPECTION <br /> INSPECTION BY .IH. DATE INSPECTION BY DATE <br /> EeH .1426 Rev. • 1-74 ol/77 _ 2M <br />