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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.O FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APP CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-375 <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> 704 <br /> d Yrl <br /> JOB ADDRESS/LOCATION Arr,A jyps,� CENSUS TRACT <br /> Owner's Name �� '�Aile r6 m r Phone f <br /> Address _ `JG 6� - '�.l p��d y City <br /> t i <br /> Contractor's Name -.� License 4/�TPhone cj! ,r� <br /> t <br /> i <br /> TYPE OF WORK (Check): NEW WELL/7—/ , DEEPEN RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / 'PUMP REPAIR JZ/ PUMP REPLACEMENT /7 <br /> Othei t/ Jf <br /> DISTANCE TO NEAREST: 'SEPTIC TANK-n" SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL. S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable Tool Dia. of Well Excavation � , <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casingev <br /> 'c Irrigation i Gravel Pack Depth of Grout Seal �. <br /> Cathodic Protection_ Rotary Type of Grout <br /> Disposal t Otl er Other Information <br /> Geophysical - { Surface Seal Installed By: <br /> " - <br /> PUMP INSTALLATION: Contractor <br /> Type of <br /> Pump `'tie H.P. (o d g <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done 40 tam 6a�sC <br /> DESTRUCTION OF WELL: .Well Diameter Approximate Depth i <br /> Descrilie Material and Procedure <br /> A <br /> I hereby'agree to comply with,jall 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 knowl e d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALS SO ' <br /> SIGNED ITLE �/ 4 <br /> f RAW PLOT P LAN ON RRVERSE SIDE 'i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ICATION ACCEPTED BY �.� `� DATE <br /> TIONAL COMMENTS: t T <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ;4a DATE <br /> 1177 .. 2M <br /> E H 1426 Rev. 1-74 <br />