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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> OF: <br /> F20FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 77 <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 Di.str .ct. <br /> JOB ADDRESS/LOCATION A.i-C4>4A 11 86rI?7- W,13 Y CENSUS TRACT <br /> Owner's Name SA661t7iGrY fAS T W,4) T/"� y <br /> Phone <br /> Address .15-2 r- lr_4/+V-A/ T S7 � /,%City _',Sl d CeEyh✓ <br /> Contractor s Name <br /> Arek Wfll W f4 U I P C 0, License 044,92 Phone'j _&SW <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / / RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other- / T W,I <br /> e7f Z,j M <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES 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 /> T Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ( Rotary Type of Grout s <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 <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 19,4MIN D ,FINA INSPECTION. <br /> SIGNED TITLES , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY C•7P DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY Elp DATE _ <br /> I I17 _ ., 2M <br /> E H 1426 Rev. 1-74 <br />