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c� <br /> r 'N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 160. -1. Hazelton Ave. , Stockton, Cal_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J_/gy k-) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 7,7-11714)0 <br /> 7 /7�p <br /> ssued 3-3-7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a t to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Healthy District. <br /> JOB ADDRESS/LOCATION //, Li [i �-,/r e gi kV CENSUS TRACT LOC// <br /> Owner's Name k{ ,' f Phone <br /> Address 'j4_?��_GL f G�,�'.� / City zn 0Y/ <br /> Contractor's Name _14,^y, 6 t L p l( n / License Z Phone 2K -s�S- <br /> TYPE OF WORK (Check) : NEW WELL /TKDEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /L/iYUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other /7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial tale Tool Dia. of Well Excavation N <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic ' <br /> /public Driven Gauge of Casing <br /> ZIrrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv: ,7T <br /> - T/i !� C <br /> PUMP INSTALLATION: Contractor A ) [ fr e <br /> Type of Pump t"Ur A,Ai ,, 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 TO GROUTING AND INAL INSPE <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> a _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I X Y <br /> APPLICATION ACCEPTED BY L° � � � DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �� / :. /7C W <br />