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► r _ <br /> toVIA �m�€a f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,G-7 S 910 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> { Application 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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION :,.� ' ,�'� CENSUS TRACT <br /> Owner's Name d V r t Gc-t ,S'6 r Phone <br /> Address ----- ��a d� s �](.� fG. � City _ <br /> Contractor's Name License # ly e Phone 74 <br /> J <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN' /�/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR Z PUMP REPLACEMENT /-J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1, <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 1.4 Cable Tool Dia. of-Well Excavation <br /> Lp <br /> F Domestic/private Drilled Dia. of*.Well Casing �{ <br /> Domestic/public Driven Gauge of Casing <br /> i � Irrigation 1 Gravel Pack ` Depth of Grout Seal { <br /> F Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' �� <br /> Geophysical , Surface Seal 'Installed By. _ <br /> PUMP INSTALLATION: ` Contractor s3� <br /> Type.-of Pump H.P. C1 <br /> PUMP REPLACEMENT: / / ' State Work. Done, .` <br /> s, <br /> PUMP .REPAIR: / / State Work Done l D .,• <br /> DES-TRUCTION 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 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 /> information is true to the best of my knowledge and-belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GR9 N AND A FINAL INSP - <br /> SIGNED TLE <br /> A KDW..P T PtAN ON RAE SIDE) <br /> i <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE D/6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II 5ROUT INSPECTION.- w PHASE III/FINAL INSPECTION <br /> INSPECTION BY. -DATE INSPECTION BY DATE // � '/ �I <br /> 3/76 ., 2m <br /> E H 1426 Rev. 1-74 _ <br />