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,�c•ht / y�d SAN JOAQUIN LOCAL HEALTH DISTRICT tl <br /> Fdz' OF1gCE USF: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ZI <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__2 //and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /rn S, Arv4 pn 444e jl4p 17—Ij ', M,,& to CT: CENSUS TRACT <br /> tv <br /> Owner's Name C -�i rr Phone <br /> Address N �r'Z' .! City <br /> Contractor's Name ac.. License #/Y; Phone L/./L- 7t> <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 4 PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done A*4 �G11 _ r9J'L <br /> DESTRUCTION 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 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 GROUT NG AND FINAL I IO'N.. . <br /> SIGNED . TITLEy� � <br /> (DAW P OT PLAN �ON R ERSE SIDE) <br /> F-VR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY M��� DATE ` _ <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE O <br /> 0/77 2M <br /> E H 1426 Rev. - 1-74 <br />