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SAN JOAQUI <br /> O NOLO_CAL HEALTH. DISTRICT <br /> FOFFICE USE: <br /> � 601 E. Hazelton Ave, ,, Stockton, Calif, r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V-7974J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f0Ce 77YE,i (Complete In Triplicate) _ <br /> t Application is hereby made to the"San Joaquin Local Health District for a permit to <br /> oconstruct <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/LOCATIONX � <br /> ? z 9CENSUS TRACT . <br /> k <br /> Owner's 'Name 6Phone <br /> Address ef C116f City <br /> 04 <br /> Contractor's Name License # Z,3Phone ' -4013/ <br /> :f&=2:f_��44 <br /> .� <br /> TYPE OF WORK (Check): NEW WELL /j_t1�'DEEPEN/ J RECONDITION /_ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICtTANK SEWER LINES PIT PRIVY <br /> �( SEWAGE ..DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> (` PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4N <br /> Industrial f Cable Tool Dia. of Well Excavation r r <br /> Domestic/private t Drilled Dia, of Well Casing A* <br /> Domestic/public f Driven Gauge of Casing / J ► <br /> .Irrigation I Gravel Pack <br /> Depth-of G-rout' Seal—"-"' <br /> Cathodic Protection I / Rotary Type of Grout ALW 6i2 <br /> Disposal t Other Other Information ' — <br /> Geophysical Surface seal Installed By: <br /> PUMP; INSTAI.LATION: Contractor <br /> Type of Pump H.P. <br /> PUMP .REPLACEMENT• <br /> / / State Work Done <br /> PUMP .REPAIR: I <br /> f State..Work. Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 A GROUT INSPECTION <br /> PRIOR TO GR TING AND F AL INS CT ION <br /> SIGNED TITLE ' <br /> DRAW AN 'ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS., <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE =INSPECTION BY DATE <br /> . GJ -t <br /> ,�+ / r�,(� f <br /> E H' 1426 Rev. 1-74 1 ��� - �'�Alt, ' .� ( � � 6`'"'�i <br />