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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 4 <br /> Telephone: {209) 466-6781 <br /> 10/1 APPLICATION,.FOR'-WELL, CONSTRUCTION: OR PUMP PERMIT ., Permit No. � 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED. : Date Issued � . . <br /> (Complete in Triplicate) s` <br /> Application is hereby made to the .San Joaquin Locdl. Health District fox` h pexini t to canaCruct� <br /> and/or install the work herein described, This application is made in comp]iance with San-•.Joaquin <br /> County Ordnance No. 1 ui <br /> And the Rules and Regulations of the San Joaqn Local Health District. <br /> -24 04 g �� {=-' id`;�F�� ..WtS n 1 <br /> JOB ADDRESS/LOCATION i4w S- - L �;� .rb ' CENSUS TRACT <br /> Owner's Name 1 �' Phone <br /> 6 <br /> Address <br /> Contractor's ame _ X Lice ey 3fU�3.7�'Pha 36/945/7 <br /> - .. <br /> TYPE OF WORK (Check) : NEW WELL % DEEPEN -/7 RECONDITION'/7 DES TR ON f-7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR•/? PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC-STANK- SEWER LINES PIT PRIVY• ,.,-,,1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -_ PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A 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 Pr_otect_ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. ' <br /> PUMP REPLACEMENT: .,, /29;1_�S tate Work Done AE)g2i a-c-e 2cs l4 P Gu.�P B AVC w �� /Ca ffR <br /> -T�- l......�_,_,.._., <br /> PIM {REPAIR: / / State Work Done �.-- <br /> DE&TRUCTION. OF WELL: Well Diameter Approximate Depth <br /> Describe�Material and Procedure <br /> I hereby agree to comply .writh 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..wel a above <br /> information is true to the-best -of- my-knowledge .and belief. I 'GROUT I <br /> PRIOR TO GROUTING"AND A FINAL INSPECTION. <br /> SIGNEDTI E <br /> {D W PLOT PLAN ON VERSE IDE <br /> • FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE �-/ <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PRASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION ..BY DATE z,a 7! <br /> 01 <br /> E R 1426 Rev. 1-74 f , , !:/75 2M'-�, <br />