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Y FOP: JOAQUIN -LOCAL HEALTH DISTRICT <br /> .'OFFICE USE: 160 y Hazelton Ave. , ,Stockton, Cal <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �'ly <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Jogquir <br /> County Ordinance No. I 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Ei 3 <br /> JOB ADDRESS/LOCATION j f � ` A rni' W a III ZRLUD N CENSUS TRACT <br /> ;1 <br /> Owner's Name S;((-VA 5oN5 Ai2jy Phone <br /> Address City Gm <br /> Contractor's Name .License # Phone 7� -JJr'70 <br /> 'I <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN/ / RECONDITION /-7- DESTRUCTION <br /> PUMP INSTALLATION /V/'PUMP REPAIR / / PUMP 'REPLACEMENT /? �^ <br /> Other / / . 01 <br /> DISTANCE .,TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL'FIELD CESSPOOL/SEEPAGE 'PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELLT <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 By: <br /> PUMP INSTALLATION: ContractorGe)EtiJ 7j i*Y1 <br /> Type of Pump W-51O.WD-VUS-00 -k)R13U C=: -11Q.t�7 H.P. <br /> l��Z.L' <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 /> II hereby agree to comply with all laws and 'regulations of the San Joaquin Local Health 'District <br /> i 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 ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG G 4AD A FINAL INSPECTION. <br /> SIGNED TITLET <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �— <br /> APPLICATION ACCEPTED BY ,,,� Q'!eekAj DATE <br /> ADDITIONAf COMMENTS: <br /> iPHASE IZ.GROUT JNSPECTION PHASE III/FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - E H 14126 Rev. 1-74 <br />