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r <br /> F iJOAQUIN LOCAL HEALTH DISTRICT f` <br /> FOE OFFICE USE: 160.L...- ,. Hazelton Ave., Stockton, Cala <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> 4pplication 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa ui L 1 e listrict. <br /> ,.JOB ADDRESS LOCATIONT r <br /> ADDRESS/LOCATION -- , <br /> - - -- - <br /> � .�r� <br /> Owner's Name Phoria <br /> �Ldress City <br /> I� <br /> iContractor's Name W / &/ License ���5'� Phone / <br /> TYPE OF <WORK (Check): NEW WELL.&T DEEPEN / / ' RECONDITION DESTRUCTION f� <br /> — —— <br /> PUMP INSTALLATION / / —PUMP REPAIR / / PUMP REPLACEMENT /- <br /> L } Other - <br /> MISTANCEiTO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> j SEWAGE DISPOS�IELD 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 /> � 1Vomestic/private Drilled Dia. of Well Casing <br /> 1 Domestic/public Driven Gauge of CasinnSeal Irrigation Gravel Pack Depth of- Grout <br /> Cathodic Protection Rotary Type of Grout <br /> I Disposal Other . Other Information, <br /> Geophysical Surface Seal Installed By: <br /> r t <br /> (;PUMP INSTALLATION: Contractor - <br /> 4 Type of Pump H.P. <br /> kPUMP REPLACEMENT: . / / State Work Done <br /> !PUMP .REPAIR: J / State Work..Done <br /> �DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Fi Describe Material and Procedure <br /> , (III 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 /> (WELL DRILLERS REPORT of 'the well and notify them before putting- the:-well in use. The above <br /> ' linformation is' true to the best of. my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG D A FINAL INSPECTION. _ <br /> SIGNED TITLE <br /> D W I' T PLAN 'ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> � <br /> APPLICATION ACCEPTED BY, � DATE sS -- <br /> I-ADDITIONAL COMMENTS: _ <br /> P S II GROUT INSPECTION PHA I/ INAL INSPECTION <br /> INSPECTION BY _ DATE t5` INSPECTION BY; DATE, -Z6-'77 -- - <br /> 3/76 2M <br /> E H 1426 Rev. ]-74 <br />