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vA✓�c ' <br /> AN JOAQUIN LOCAL HEALTH BISTRICT -- -- <br /> FORrOFFICE USE: &V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S--a 93.1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM BATE ISSUED Date Issued 7 f- <br /> 2S'" ! <br /> (Complete In Triplicate) 0 Qd—teo- zy <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 ` -.41 CENSUS TRACT <br /> Owner's Name ] Phone AIJV _J�1110 1 <br /> Address : 69, City S pco*j <br /> Contractor's Name �� _f�. r� .•__. License' # Phone <br /> x <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION09 <br /> PUMP INSTALLATION REPAIR / / PUMI'.REPLACEMENT _7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PfT 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 /> 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 /> �: .Disgosa3: - , �` �Other��. �.ori,, 'Other-Information <br /> Geophysicai- Surface Seal Installed B i <br /> l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /' / State Work Done ' { <br /> PUMP '.REPAIR: /-7 State Work Done - <br /> �, � _ <br /> ,�ES RUCTION OF WELL: Well Diameter �. .APP oximate Depth � • <br /> ,,Describe Material and Procedure u <br /> I hereby agree to comply_with all laws and regulations of the Sari 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-he atyof-my-knowledge-and-belief.---I-.WILL-CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING-,ANDk'A FIN INSPECTION. �M1. <br /> SIGNED - -� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _ FOR DEPARTMENT.USE ONLY .__..__.•_ <br /> PRASE I <br /> APPLICATION ACCEPTED BY ZZ 1z DATE <br /> ADDITIONAL COMMENTS-. — E4` <br /> PHASE' II GROUT INSPECTION PHAS. II 4/MAL 4NSPECTILN ' <br /> INSPECTION BY DATE "- '°`INSPECTION'`BY "" ATE 7 ZUZZI <br /> rvE R 1426C <br /> Rev. 1-74 <br /> 1-74 �hri <br />