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_ SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 'QF CrFFI ,USE:` 1601 E. Hazelton, e.? Stockton, Calif. �,;/), e C6 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perm No. 3D <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED, Date Issued. <br /> (Complete In Triplicate) <br /> Application is Ne r y 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 Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION Q 3 7 <br /> /�/ CENSUS�TRACT <br />.Owner's Name Aw p P, ye c, Phone :Z_?G <br /> AddressCity <br /> Contractor's Name _N�A.L.. AV,4, WAO icense.. Phone sX/4-s <br /> 7 7 <br /> TYPEQF WQ ( heck) : NEV-dEtL� D N ' CONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALL ION &/7P REPAIR / / PUMP REPLACEMENT <br /> Other.. / / — — <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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of_ Well Excavation �J <br /> X Domestic/private Drilled -I)ia. of Well--Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal sem— � <br /> Cathodic Protection Rotary Type .of. Grout <br /> Disposal Other Other. Information 5L/�IFUl..i 44- <br /> Geophysical Surface Seal Installed By: L Gig <br /> PUMP INSTALLATION: Contractor (�//►r�- <br /> Type of PDnp�o ,S' H.P. l <br /> PUMP REPLACEMENT: / / State rF Dan <br /> PUMP -.REPAIR: / / State Work Done <br /> z/ -i�✓ /9�S sz r✓!a Y <br /> DESTRUCTION OF WELL: Well Diameter Approxima e Depth l¢ <br /> Describe Material and..Pro.cedure <br /> I 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 'cons.truction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the;,,Sari 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 is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A INAL INSPECTION. <br /> SIGNED TITLE <br /> 61 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �-� <br /> APPLICATION ACCEPTED BY UtJ DATE �l" / <br /> ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTIO PHASE I/FI AL INSPECTI N <br /> INSPECTION BY DATE I INSPECTION BY DATE <br /> E H 14-2-6_ Re-v- 1-74--- <br />