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1.-.i�s9 SC^ — —. -.-.a. .. / Y. ( ♦ l .y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_R7OFFICE USE: ;6 ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> { rA Telephone: (209) 466-6781 <br /> A4 I APPLIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-31- 7d <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. 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> " JOE ADDRESS/LOCATION, ROWMAN RL CENSUS TRACT <br /> Owner's Name (/ Phone 0 <br /> Address 2. -Z W. Rowmmy City Ejef, d✓cp <br /> i <br /> Contractor's Name /®/ jA7 _ _ _.License Phone <br /> TYPE OF WORK (Check) : NEW WELL_._DEEPEN , RECONDITION ./-7,,-..DESTRUCTION /_7 N <br /> ' PUMP INSTALLATION / / PUMP REPAIR / / . PUMP REPLACEMENT <br /> k Other / # — N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD " " `j CESSPOOL/SEEPAGE PIT OTHER 0 <br /> PROPERTY LINE = PRIVATE DOMESTI`C'mWELL PUBLICmDOMESTIC WELL G <br /> INTENDEV USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cab1e Tool Dia, of Well Excavation 10-110, <br /> Domestic/private z Drilled-` .� Dia. of Well Casing <br /> - Domestic%public_- -Driven- ­ ..§„--.`_ Gauge -of Casing <br /> Irrigation Gravel-.,Pack Depth of Grout Seal <br /> k Cathodic Protection Rotary Type of Grout <br /> Disposal_f Other Other Information -� <br /> Geophysical Surface Seal Installed By: ,A1QAC,1< _ <br /> f, <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT; X = State Work Done Q�►�L ',[n �U � ��!'f/ -(�,�"GL <br /> PUMP REPAIR: / / State Work Done <br /> ! DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and,'Procedu:e +� <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 DAIS <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.djtrue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR TO GRNG AND AJAJAL INSPE T ON. 14& <br /> SIGNED TITLE -4 <br /> (DRAW PLOT.PLAN ON.REVERSE SIDE) ._"- <br /> f OR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> t APPLICATION ACCEPTED BY . DATEJ T <br /> ADDITIONAL COMMENTS: (Z 77 <br /> PHA E II 5ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / 7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-.74 _ -- -- - <br />