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$AN'SOAQUIN LOCAL'HEALTA DISTRICT <br /> F0BiOFFICE USE: 1601 E. 'Haaelton`Ave.,'Stockton, Calif. <br /> Talephone:'1 (209)_466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;77 15- <br /> THIS YERlffT'EXPIRES 1 YEARnP{tOM DATE ISSUED Date Issued -may-7J <br /> ,,(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local,,gealth 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 146. 1862 avid the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION )S-104 CENSUS TRACT <br /> Owner's Name �a.. c .. Gro..;�,/�{r` Phone <br /> H <br /> J !!i /•W feet <br /> n ' tT1• <br /> Address City L.p.t:ti <br /> V n � <br /> Contractor's Name_ b)rEC go{..., i�p n kf e_,e Oc S '-,License 0 Phon 3 ySlo <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITA 7 UCTION LT <br /> PUMP INSTALLATION L3 PUMP REPAIR / CEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK S 'LINES PIT PRI <br /> SEWAGE DISPOSAL CESSPOOL/SEEPAGE IT OTHER \ <br /> PRO - PRIVATE MESTIC WELL, PUB IC DOMESTICWELL <br /> INTENDED USE 4) OF WELL CONSTRUCT ON SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Exca ation <br /> ..Domestic 1priv a Drilled Dia. of Well Casi g <br /> Domestic/public Driven Gauge of Casing,, r �---_ <br /> -Zriigatio'n V 'a Grave Pac1�k �bepth of Grout Se 1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1`^ Other Other Information <br /> Geophysical j1 Surface Seal Instilled By: <br /> PUMP INSTALLATION: Contractor Nei <br /> Type of Pump rM L I H.P. <br /> PUMP REPLAMMNT: State Work Done <br /> PUMP :REPAIR: 7 State Work Done u <br /> _ 1 <br /> PBSo UCTION OF WBSLIa�l iamater proximate Depth I <br /> I hereby agree to comply with all laws and regulations of the San Jo quin Local Health District { <br /> and the State of California pertaining to or regulating well conetru tion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Jo quin Local Health District a 1 <br /> WELL DRILLERS REPORT of the well and notify them before putting the . 11 in use.. The above <br /> information is true to the beat of myknowledge- and belief. I WILL FOR 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 .F <br /> PHASE I gQr t <br /> 'LICATION ACCEPTED BY h: DATE 123-7 1 <br /> JITIONAI•COMMENTS: <br /> PHASE I ' ROUT INSPECTION IIF AL INSPECTION <br /> INSPECTION BY j I&1= DATE INSPECTION BY DATE <br /> �- y, <br /> E H 1426 Rev. 1-74 <br />