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a r, c y; `JJOAQUIN LOCAL HEALTH DISTRIC'��,,,,// <br /> FOE 0•FICE USE: 160 VC Hazelton Ave. , Stockton, Callen. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 7-375 <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-1-41-- 7 7 <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Tud/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 Health District. <br /> -OB ADDRESS/LOCATION r CENSUS TRACT <br /> aner's Name l! ,//a e-� Q r t� Phone <br /> Address City <br /> `:)ntractor's Name License 11 ; �y j-Phone j. -7E C <br /> fPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION DESTRUCTION /—T <br /> ` PUMP INSTLATION REPAIR /�(/ PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> 4PISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 n <br /> Domestic/public Driven Gauge of Casing y� <br /> _Zr Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump T r n 2 !'� H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP REPAIR: / / State Work Done ; <br /> iSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> dnd 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 /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation 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 /> IGNED TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> -HASE I <br /> PPLICATION ACCEPTED BY bG DATE <br /> TbDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY ' DATE <br /> l !77 9M <br />