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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR(OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z �D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -p <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 anis the Rules and -Regulations of the San Joaquin Local Health District. <br /> G JOB ADDRESS/LOCATION 2 S G F CENSUS TRACT <br /> Owner r s Name CN A-/2 A M O Od E --- _ � Phone <br /> Address _ SA ,City 57-0C-k b1L1 <br /> Contractor's Name 1 U p /NG License #,2peZ y Phone JIVL M.7 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /�J_ PUMP REPAIR J / PUMP REPLACEMENT f7 <br /> Other : <br /> a <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 /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> geQ <br /> 4 _ Domestic/private +i Drilled Dia, of Well Casing <br /> Domestic/public .1 Driven Gauge of Casing <br /> Irrigation c Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ► Rotary <br />� - y Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: A/DAcfC <br /> PUMP INSTALLATION: Contractor C IMC <br /> p. <br /> Type of Pump s G//9MF2S11�`E, �' H.P. <br /> _ <br /> PUMP REPLACEMENT: /_7 State,-Work,.-Done <br /> PUMP REPAIR: /-7 State Work--Done <br /> E&TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe MateriaV 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 well and notify them before putting. the..well in,.use.. The above <br /> information is true -to••the-best e of--my?knowledge and belief. I -WILL -CALL: FOR A-GROUT INSPECTION <br /> i 'PRIOR TO GROWTING AND AfINAL I PECTION. ��V� �\N <br /> SIGNED TITLE <br /> - (DRAW PLOT-PLAN ON-REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE !Z:: �'� INSPECTION BY DATE T-7-o 7 <br /> 1 'E H 1426 Rev. 1-74 1-74 2M <br />