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C V JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOR-eOFFICE USE: 160.x.. Hazelton Ave. , Stockton, Cal__. <br /> Telephone: (209) 466-6781 ' <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74,e- 31/g oe <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued as-11 <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 Joaqui: <br /> ` County Ordinance No. 1862 and the Rules and Regulations of the -San Joaquin Local Health District. <br /> JOB ADDRESS LOC �-S. <br /> ADDRESS/LOCATION .( �f CENSUS TRACT <br /> " Owners Name 4 �'� C5 `/V Phone <br /> Address fo - Com[ - � �} T1b�` � City <br /> [� Contractor's' Name z , c fig- ` U/�-�� S �Lr� License <br /> TYPE-OF WORK (Check): NEW WELL/? DEEPEN J RECONDITION /-7 DESTRUCTION (7 - ti <br /> PUMP INSTALLATION L PUMP REPAIR /_J PUMP REPLACEMENT 17 <br /> Other /_7V . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B, <br /> ti <br /> PUMP'INSTALLATION; Contractor ;Dz_�91P <br /> Type of Pump ? H.P. <br /> r PUMP,REPLACEMENT: / / State Work Done/Ou i-t- COT- <br /> E PUMP 'REPAIR: L7 State Work Done <br /> C ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> F Describe Material and Procedure <br /> 4 <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 /> F 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 FINAL INSPECTION. <br /> SIGNED TITLE � ) <br /> (DRAW PLOT PLAN ON REVERSE SIDE_ <br /> •FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7j <br /> ADDITIONAL COMMENTS: 5 <br /> PHASE TI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,2� <br /> k .- <br /> 'j. - - <br /> t E H 1426 - Rev. 1-74 1_74 9M <br />