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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `7 7 - .73VW✓ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is fiereby 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 Joagpin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LocATION _ j ,Wa CENSUS TRACT 2-2 -d`EO-a� <br /> Owner's Name •r�LfZ Phone -9,5 F_;�`Z3.4 <br /> Address Citya jv° <br /> r <br /> Contractor's Name �l� � �.Q/ �.� - �f/� ��1r License <br /> Z16 Phone <br /> TYPE OF WORD (Check) : NEW WELL / DEEPEN /_ RECONDITION f_1 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY O <br /> SEWAGE DISPO FIELD CESSPOOL/S EPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS s <br /> Industrial Cable Tool Dia, of Well Excavation 1 <br /> Domestic/private Drilled Dia, of Well Casing <br /> iomestic/public Driven Gauge of Casing <br /> rrigation Gravel Pack _Depth .of Grout Seal14 41 \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information c <br /> Geophysical Surface Seal Installed By: C3'Crr7,�TP/�— <br /> PUMP INSTALLATION: Contractor ^ <br /> ' Type of Pump H..P....fQ® <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well ,Diameter— -�- � -- =—" Approx te-DePt4e - <br /> Describe Material 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 Aistrict 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 4 FINAL INSPECTION. <br /> SIGNED TITLE .�i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DPPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FTNAJ, INSPECTION <br /> IRISPECTION BY 4a4L DATE INSPECTION BY DATE IZ4 <br /> E' H 1426 Rev. 1-74 �-Q`� - 117.7 2K ,,, <br />