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a'►+ f✓��jr SAN JOAQUINLOCAL"HEALTH DISTRICT <br /> FOFt OFFI USE: 1601 E. Hazelton-.Ave. , Stockton, Calif. r <br /> Telephone : (209) 466--6781 //ll <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. +7..�� <br /> THIS PERMIT EXPIRES 1 YEAR" FROM DATE, ISSUED Date Issued 3 <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. 1$62 and -the Rules and Regulations of . the San Joaquin Local Health District. <br /> x,77 rZ � Y <br /> JO ADD SS/LOCATION 6 . 47 ,,, 46AS P CENSUS TRACT <br /> /". <br /> Owner's Name � �Ist t!a�� Phone <br /> Address � 4 - <br /> a City � Gie <br /> Contractor's Name ,5y License # 1f.4-991hone -7,� � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/-7/- RECONDITION /w/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /f/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE z TYPE 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 of Casing <br /> 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 /> PIMP INSTALLATION: Contractor r� <br /> Type of Pump H.P: ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I-hereby agree -to coinply 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 kno led e-._ d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO R UTING AND A FINAL INS C ON <br /> SIGNED TITLE <br /> �^rl' <br /> ( AW PLOT PLAN ON RUVERSE SIDE) f <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "' DATE "Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION w PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION BY f/r DATE 3 -3 o -7 9 <br /> .�. _0,�l7 2M .4 <br /> -E H 1.426 Rev.., 1-74 _ <br />