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diaJ,vi -/C <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF uFFicE USE: 1601 E. Hazelton'Ave. , Stockton, Calif. �v <br /> Telephone : (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7"/3od/ <br /> ja ( THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereb' 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 X;?0.5-,� jF� CENSUS TRACT <br /> Owner's Name �VcPhone F ZAV � <br /> Address v aao City Fe5c ob—f dp[! <br /> Contractor's Name License # JY40710 Phoney s32-3/8` <br /> 7--/Z <br /> 11 t <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION IV 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 v. <br /> Industrial Cable Tool Dia, of Well Excavation �7 C <br /> Domestic/private Drilled Dia, of Well Casing dI <br /> Domestic/public Driven Gauge of Casing <br /> 40, Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />)ES,TRUCTION OF WELL: Well Diameter Approximate Depth - �-'— <br /> �(/v /Describe Material an—'C—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 /> 4ELL 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 />'RIOR TO GROUTI ANDA FI4L INSPECTION. <br /> SIGNED tj. TITLE e- �) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br />'HALE I <br />'APPLICATION ACCEPTED BY DATE <br />-kDDITIONAL COMMENTS: <br /> PHASE GROUT ,INSPECTION PH <br /> Y, ASE I INAL SPECTION <br />'INSPECTION BY t - DATE / INSPECTION B DATE <br /> 2M <br /> E H 1426 Rev. 1-74___I_ <br />