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re�_SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMi 9RMCT Permit No. <br /> q�, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE IhIPEDDate Issued 7) <br /> / �:(o� Y. IF 77AMArtJE Rd (Complete In Triplicate) efO -(iJ <br /> 1pplication 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 /> Jounty Ordinance No. 1862 and the Rales sand Regulations of_the San Joaquin Local Health District. <br /> y��f <br /> JOB ADDRESS/LOCATION �i to / � '` ! /.�#L- /2 P (;a CENSUS TRACT �C <br /> Al., y 7 <br /> Owner's Name � ,r�",rrir � rrs^, Phone �r G A'�Gv/ <br /> Address City A&r -1— !f mea <br /> Contractor's Name > -.fe« + '` 4 License Phone � 'y <br /> r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION YX PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY °Q <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 All <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 Q /-e <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor L { s 7 <br /> Type of Pump H.P. (� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done OOOO <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 GROUTING AND A'PNAL INSPECTION. <br /> SIGNED TITLE <br /> i <br /> "L (DRAW PLOT PLAN ON RE FRSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> P 3E I <br /> A6, ICATION A PIED B f-iry _ DATE LO- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 3P/ 41EFI��NALINS�PECTIINSPECTION BY DATE INSPECTION <br /> -77 <br /> i <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />