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. JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 Hazelton Ave. , ,Stockton, Cali. ! <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP P er-mi"o- ,P---,=— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y ?� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to coxistruct' <br /> and/or install the work herein described. This application is made in compliance with .San J94"quir <br /> County. Ordinance No. 1 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 y . Yq hi N e-CENSUS TRACT <br /> Owner's HameTN _s2ILVA SONS_IA1RW � Phony <br /> Address _.2.R Q D-Gk1-MN 0 RD City ffi�.gmVn <br /> Contractor's Name _C;L?F.RI t G TU rnp License #73Q90� Phone" -7554 . <br /> TYPE OF WORK (Check): NEW WELL '/ .DEEPEN /.7 RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION /Fj PUMP REPAIR / / PUMP 'REPLACEMENT /7 �^ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK , ' . ,SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSA -FIELD­­--- "Z;ESSPOOLISEEPAGE. PxT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 'S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATIONS: <br /> . <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 "Gr6ut.'Sea1 <br /> Cathodic Protection Rotary Type of Grout ^ <br /> - Disposal Other Other Information <br /> - Geophysical Surface Seal Iristalled Bye <br /> PUMP INSTALLATION: Contractor c��Q6m-"RN 'lump <br /> Type of Pump bla _oWn 110:50-0 40Rja Cn L_-_ L4 11ew H.P. :5o <br /> WELL <br /> PUMP REPLACEMENT: . F7 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 Healthistri+ct <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 ue to the best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G " G 4AD A FINAL INSPECTION, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> OR DEPARTME1jT USE ONLY <br /> PHASE I � _ � <br /> APPLICATION ACCEPTED BY 41- /n, J DATE <br /> 4DD IT I ONAL`"COMMENT S <br /> PHASE: II,GROUT;=INSPECTION PHASE III/FINAL'INSPECTION <br /> 'SPECTION BY DATE INSPECTION BY DATE <br /> H 1426 Rev, 1-74 <br />