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ti <br /> r I SAN-JOAQ'U N LOCAL HEALTH DISTRICT <br /> FW'OFFICE USE: 1601 E. Hazeltoin Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-/6a p <br /> I .. <br /> THUS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .,. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Realth 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 /> JOB ADDRESS/LOCATION 110 (Al-c" n4 CENSUS TRACT <br /> Owner's Name .{ (� ,� <br /> ��t`-2. 1 � .�Gn �i 'Cf-' .,_..., .... hone <br /> Address ;, City <br /> Contractor's Name /0 9�s 46,�.� ILicense # Phone-Sr`j P 3 ysc <br /> (Check).,• /? DEEPEN RECONDITI •'---�_� DESTRUCTION <br /> TYPE OF WORK Check . NEW WELL /7 ON RUCTION <br /> PUMP INSTALLATION � PUMP REPAIR /—/ PUMP REPLACEMENT- %7 <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK . . SEWER LINES PIT PRIVY <br /> SEWAGEiDISPCSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialA Cable Tool Dia. of Well Excavation p <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing = Q <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal A Other Other Information <br /> Geophysical Surface Seal. Installed By: _._,_..... ,,. <br /> PUMP INSTALLATION: Contractor ,,ta A <br /> Type of Pumpmd- _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-.REPAIR: 17_„rState Work Done <br /> ,PES TRUCTION_ 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 /> 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-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALS INSPECTION. <br /> SIGNED ! TITLE .� <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE ��� ✓el�T <br /> ADDITIONAL COMMENTS: <br /> PHASE OUT INSPECTIONHA I/ f NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i <br /> I E H 1426 Rev. 1--74 I-74 2M <br />