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{ r d <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT M I L ?;6,7e,*4 J --T f 0 <br /> FOS: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. U�I�FR <br /> . Telephone: (209) 456-6781 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedW 281977 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e�7AIIVA '✓ CENSUS TRACT <br /> Owner's Name Ve, ve-- Phone ?,3,r'12-S0 <br /> Address A 66 V `z—- City <br /> Contractor's Name QL✓iy License # Phone <br /> s .— <br /> �i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION / /_7_/ DESTRUCTION / <br /> PUMP INSTALLATION /, PUMP REPAIR / / PUMP REPLACEMENT <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 G ail -J4'2 <br /> Type of Pump 2-�i H.P. S' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work, Done <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 G9 TING ANDA FINAL INSPECTION. <br /> SIGNED } TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �'Z 2 Zr / / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOIJ PHAS /FIN INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY PV 1 ATE 7- <br /> E <br /> E H 1426 Rev. - I-74 n/77 2M <br />