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r w� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> °FOR OTFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466--6781 C� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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'., 188662 ®afithe Rules and Regulations of the San Joaquin ocal Health District. <br /> JOB'-ADDRESS/LOCATION ! d PI)TVS <br /> AT TRACT <br /> Owner's Name s <br /> d <br /> ZF1/ s>a Phone — 3 Vol <br /> Address 2-1 Z - 4 <br /> D h/ City A Pa <br /> Contra NameiL 4AL9 <br /> License # Q0 Phone g <br /> TYPE'.QF�WORK I-(Check) : .NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 <br /> !> 3'4 ! PUMP INSTALLATIONfi�'PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> 'Other <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK/Ake SEWER LINES1aOtl PIT PRIVY <br /> I 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 <br /> Industrial 1 Cable Tool Dia, of Well Excavation /Z <br /> Domestic/p.rivate , t Drilled Dia, of Well Casing fj <br /> Domestic/public rI Driven Gauge of Casing ME <br /> IrrigationGravel Pack Depth of Grout Seal Vl. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contfactor aw� � _ D I5 4.l Q 70 <br /> Type of Pump OAJ H.P. <br /> PUMP REPLACEMENT: ; � n C 5 N U <br /> State Works Don�.� a �y^7 Ca eU <br /> PUMP .REPAIR• w�{ /�'/ ..State Work Done <br /> DESTRUCTION OF WELL: Well Diameter � �� "'- - Approximate-Depth <br /> Describe Material and Procedure F <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 A GROUT INSPECTION <br /> PRIOR T ROUTING ANDA AL INSPECTION. <br /> SIGNED i TITLE f1WY } <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASA AIIIF;NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> n <br /> E H 1.426` - Rx-u_ 7_7A 1177 <br />