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�'� � " �° '`AN JOAQUIN LOCAL HEALTH DISTRICT' ' '43 <br /> FOF� OFF �ICE USE: 16 E. Hazelton Ave. , Stockton, Cao 11 <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL: CONSTRUCTION OR PUMP PERMIT Permit No. 791-336 A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .Date Issued 77/7- <br /> (Complete <br /> /7-(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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 V- S ✓ ��� ��. CENSUS TRACT <br /> Owner's Name r a-- r a e c U4 P n�� <br /> 1 so <br /> Address 4 S ✓ c��-r cc 41 city r�G <br /> - ------ a ro. ... - <br /> Contractor's Name a Licensee # y4'Phone <br /> 22 <br /> TYPE OF WORK (Check): NEW WELL f_T 'DEEPEN /? RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / r/ PUMP ,REPAIR / PUMP REPLACEMENT <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 /> Domestic/private Drilled Dia. of Well 'Casing <br /> Domestic/public Driven Gauge of Casing u <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> -Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical f;: Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , '1. <br /> Type of Pump H.P. ? ✓ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done i <br /> 2ESTRUCTION_OF WELL: Well Diameter 'Approximate Depth <br /> T� Describe Material and Procedure <br /> A <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 knowledg and belief,. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL.,LNSPEI , <br /> SIGNED. TITLE <br /> a RAW PLOT PLAN ON ERSE SIDE, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Iji <br /> APPLICATION ACCEPTED 'BY 11 DATE <br /> Iv- <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE 'III/ INAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />