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rb �6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f-FORIOFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V-s/.3/4 I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ay- <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 and4the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT t <br /> Owner's Name ' Ac�a5 (�d.r.1' - „-—_-- Phone <br /> i <br /> Address - City <br /> Contractor's Na License ! honet�� <br /> t <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION Z PUMP REPAIR /_7 PUMP REPLACEMENT /f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL off, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool. Dia. of Well Excavation <br /> 7C Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation : Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 7 Rotary Type of Grout <br /> Disposal ' t Other Other Information <br /> Geophysical I Surface Seal Installed„ By: <br /> _ <br /> PUMP INSTALLATIONt Contracto p w 0;0914c. <br /> Type of Pump .r H.P. 3 { <br /> +PUMP State Work Done IVo <br /> PUMP .REPAIR: L7 State Work Done <br /> ES1RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . I hereby agree to comply withfall 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,kn edg nd- bre ief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO NG AND A FINAL 'IN PE N. <br /> SIGNED - LE <br /> jE DRA T PLAN ON REV E SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY IDATE -(�{- 7 y <br /> 4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . DATE LD- K 7Z <br /> E H 1426 Rev. 1-74 1-74 2M <br />