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Cc,PY*4 It SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE O FICE USE: 1641 E. Hazelton Ave., Stockton, Calif. <br /> + � Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Ido. /Q <br /> THIS P :T EXPIRES 1 NEAR FROM DATE ISS Date Issued 171 <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 and the Rules and Regulations of the San Joaquin Local Health- District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name a kyr M to ,0 A�em Phone <br /> Address <br /> 1 �cr�"s � � /0�A� City 411,4 y <br /> Contractor"s Name <br /> License # /J-4-7xsThone VCX774,74 <br /> a <br /> TYPE OF .WORK (Check): NEW WELL f DEEPEN Jam/ RECONDITION j_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /!.PUMA' RE <br /> PLACEMENT % <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC`TANK SEWER LINES PIT PRIG (� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF 16TLL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Tia. of Well Excavation <br /> Domestic t ^ <br /> /private Dr�11ed Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - "--� <br /> Disposal Other Other Information`. <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: ,Contractor,- <br /> Type <br /> Contractor;Type of Pump ,rti✓ H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP .REPAIR: State Work Done �., � <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depthy <br /> Describe Material and Procedure ' <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 swell and notify them before putting.the- well in use-.- The above <br /> information is true to the fest of. myow dg _ belief, I WILL CALL FOR A GROLs'I INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI N <br /> SIGNED ITLE R" <br /> D PLOTLAN ON A&SE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I __ <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II b1f0UT INSPECTION P E I/ NAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE 7� <br /> E H 1426 Rev. -I-74 <br /> 6/771- 2M <br />