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Go tV& �a' �(�,C' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fw OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,4. SV-P <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued 27-7s- <br /> (Complete In Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the 'work herein described. This application is made in compliance with San Joaquin <br />' County Ordinance No. 1662 and. the Rules and Regulations of tth-e�San :Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S9,0-0 y� -r/� `� CENSUS TRACT <br /> Owner's Name -Phone _ Y <br /> i A_d(treNH City <br /> .&L. PhoneContractor's Name 776 <br /> TYPE OF WORK (Check): NEW WELL -/ DEEPEN '/ - RECONDITION /� DESTRUCTION /-7 <br /> PUMP INSTALLATION '/W PUMP REPAIR -/7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER ` - <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />" Industrial Cable Tool Dia. of Well Excavation Q' <br /> g_ Domestic/private Drilled Dia. of_Well Casing <br /> ., '_`Dumesti-d-/pub -C" - - tD Sven Gauger o£ 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 /> PUMP INSTALLATION: Contractor - <br /> e� <br /> t ` Type of Pump H.P. <br /> ' PUMP REPLACEMENT: , /%'' State. Work Done <br /> aPUMP r ' State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree .to comply with all laws and regulations of the San J"oaquin- 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 <br /> WELL DRILLERS- REPORT of the well and notify them before putting-the.-well. in-use.. . ,The above <br /> information is true to thebest-of- my� wle ge a�b�lief. I WILL CALL •FOR A GROUT INSPECTION <br /> PRIOR TO O TING AND A FINAL INSPECT N. <br /> SIGNED . - `TLE <br /> E D W LOT PL' ON REV SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E ' DATE44e.zz-L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF, I FINAL INSPECTION <br /> INSPECTION BY DATE ,FINSPECTION BY DATE <br /> v w � <br /> E H 1426 Rev. 1-74 - <br />