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- <br /> (/y(i\ � SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton;.Calif. <br /> k .: Telephone : (209) 466-678 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued RJ' 77 <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 Jogquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. j <br /> JOB ADDRESS/A.A.IT t ,� o CENSUS TRACT <br /> Owner's Name �[>U d--1yD �'i p Phone <br /> Address _ Ci o ro City <br /> Contractor's Nam ' VW Y License # t3 zJ Phone )r--74741 <br /> X <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation - <br /> s ^ 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 /> PUM�_ INSTALLATION: Contractor.�� 4 <br /> G� <br /> Type of Pump .Sl O H.P. / <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /K/ 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 Joaquin Local Health District <br /> sand 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 thewell in use.. The above <br /> information is true to the best-,of my knowledge and-b ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROIUTJN AND A FINAL INSPE <br /> SIGNEDTLE <br /> (DRAW L ON REV SE SIDE) i <br /> ir DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYZVI, <br /> DATE 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSVECTION PHASE III/FINAL INSPECTIOLY <br /> JINSPECTION BY DATE INSPECTION BY _ DATEr1177 - 2M <br /> 3 7 <br /> E 5H'=1426 i Rev. 1-74 <br />