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I� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . ., Telephone: (209) 466-•6781 <br /> dAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> m i ed4 T,HIS...PERMIT EXPIRES 1 YEAR FROM BATE ISSUED Bate Issued c�-d <br /> (Complete In Triplicate) <br /> ` Application is her <br /> made to the San Joaquin Local' Health District for a permit to construct <br /> r and/or install the work herein described. This application is made in. compliance with San Joaquii <br /> County Ordinance No. 186and.�.t u. $egul.ations of the San Joaquin Local. Health District. <br /> JOB .�ADDRESB/ - `✓ d'-� 4 " CENSUS TRACT <br /> Q d > Phone <br /> � Owner's Name �(�'G C3 _ --. - -- <br /> s /° /G, vb <br /> Address S S a �CCity <br /> Contractor's NameE4,.0 ., License # C,93 7aI. Phone <br /> TYPE OF WORK (Check) : ;ANEW WELL / / DEEPEN%/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�(/ PUMP REPLACEMENT f? <br /> I� 0 ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 7TYPE 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 ofFCasing L <br /> Irrigation IE Gravel Pack Depth of Grout Seal C <br /> " Cathodic Protection Rotary .Type of Grout <br /> Disposal E Other Other Information T) <br /> Geophysical �' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' d <br /> rf Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done '. <br /> 10-0PUMP .REPAIR: IM /K/ State Work Done /f �*1® <br /> I <br /> ` DESTRUCTION OF WELL: Well Diameter t Approximate Depth , <br /> h, Describe Material and Procedure "�- <br /> Ii f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion ofmy work on a new well, I will furnish the San Joaquin Local Health District <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 led e be ief. I WILL CALL FOR A GROUT.-INSPECTION <br /> PRIOR TO GRO I AND -,A FINAL I <br /> SIGNED m , TLE <br /> (D P T P ON RE RSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE -I <br /> APPLICATION ACCEPTED BY DATE S-26-7 ) <br /> . ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> " <br /> b/77 _ 214 <br /> E H 1426 Rev. - 1174 <br />