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AM-1 I— <br /> FOR OFFICE USE: SAN JOAQUIN OCAL„HEALTH DISTRICT <br /> 160 <br /> 1 ; <br /> E. Hazelton Ave. Stockton, Calif. l` <br /> Telephone: (204) :466-67813 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T ."� � 19'1$ <br /> THIS PERMIT EXPIRET. JAM 1 s <br /> S I. YEAR,. FROM DATE ISSUED Date Issued <br /> O✓ � - �"` 'r, (Complete In Triplicate) <br /> -�C v4 n! i t7 ev <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 /> YAM W� / <br /> JOB. ADDRESS/LOCATION. � 1 ' fd o 1 IA-"y <br /> ENSUS TRACT <br /> G <br /> Owner's Name <br /> Phone <br /> f .� y1�� <br /> Address .. - li�Li p Cityo O <br /> Contractor's 'Name s � �J License �� Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /� DESTRUCTION _ 1 <br /> ' PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT/_7 <br />{ Other f/ / — --- O <br /> F "4 <br /> DISTANCE TO NEAREST: SEPTIC1TANK 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 I <br /> 'I Cable Tool Dian, of Well Excavation- <br /> Domestic/private I Drilled Dia. of Well- Casing <br /> Domestic/public ! Driven Gauge of Casing`. R <br /> ' Irrigation I Gravel�Pack Depth of Grout Seal" <br /> y. Cathodic Protection ! RotaryI <br /> T ype of Grout <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed : <br /> PUMP INSTALLATION: <br /> F Contractor <br /> ' I <br /> x . Type of Pump ofs H.P. Z® m <br /> PUMP REPLACEMENT: / / State WorkDone <br /> PUMP .REPAIR: / / State Work Done �. <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure , <br /> I hereby agree to comply withfall laws and regulations of the._SaniJoaquin Local Health District <br /> and the State of California pertaining to or regulating well 'cansttucti.on.� .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 knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALtI SPECTION. <br /> SIGNED P_ G,J TITLE (>' <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> IPHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �r/ �Y7JC-- <br /> ADDITIONAL COMMENTS: + 4� <br /> PHASE II GROUT INSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY DATE 1, INSPECTION BY DATE <br />�_E�.H .1426 Rev. � 1-74. <br />