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r <br /> n tr. <br /> �4 SAN J'OAQUIN LOCAL„HEALTH DISTRICT <br /> F <br /> EOk OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7 7' 3s- <br /> I1� THIS PERMIT EXPIRES 1 YEAR, FROM DATE 'ISSUED Date Issued .-L ,_'-. � <br /> } (Complete In Triplicate) <br /> Application is tereby de 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 /> i' JOB ADDRESS/LOCATION. CENSUS TRACT <br /> Owner's NameOA& da vo , <br /> Phone <br /> Address <br /> Contractgr.'s Name 7hL License #12p2zv Phone "82 <br /> • ___ _ .. .. <br /> TYPE OF,WOR&(Cfieck) NEW WELL / DEEPEN / RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION L/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /% <br /> DISTANCE: TQ'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 RotaryType ype of Grout � <br /> Disposal Other Other Information �-- <br /> Geophysical Surface Seal Installed By: <br /> 1 <br /> PUTAP ..Contractor: <br /> INSTALLATION: w. F <br /> Z . .�_.... -. -..•...�..-•., ---_ .� . ..:._,� <br /> Type- of Tump '� _. .. H.P. <br /> P014P REPLACEMENT. .. <br /> State Work Done <br /> PUMP .REPAIR: / / State Work ,Done.- <br /> DES.TRUCTION "OF WELL; Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> e � I <br /> I hereby:agzee 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 notifythem before <br /> putting the well in.use. The above <br /> information �is true to t st f y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO T NG D A I <br /> SIGNED TITLE Xa6lZ Al <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION 'ACCEPTED BY DATE �— <br /> ADDITIONAL COMMENTS; 1 <br /> J <br /> PHASE 117 UT INSPjt.OTION PHASE II FINAL.INSPECTION <br /> INSPECTION BY HATE INSPECTION B DATE 4' � ? <br /> E H 1426 _ Rev. 1-14 f 1177. 2M M <br />