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-- SAN JOAQUIN.LOCAL 'HEALTH DISTRICT _ --- <br /> f0$iOFFICE USE: /"r1601 E. Hazel ton.Ave., QStockton, Calif. <br /> E <br /> Telephone: (;",(209) 466=6781 <br /> 5 <br /> APPLICATION FOR WELL CONSTRUCTON OR PUMP PERMIT Permit No. 7�-Ia1�11° <br /> THIS PERMIT E)PIRES' I ,YEAR FR M DATE ISSUED Date Issued 1,;L_1q-7Z <br /> (Complete in Triplicate) <br /> Application is hereby made toIthe San Joaquin ,Local Maalth 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 andlthe Rules- and, Regula o ,of� the San Joaquin Local. Health District.. <br /> lzg <br /> JOB ADDRESS LOCATION -e, SIC ;V s: CENSUS TRACT <br /> Owner t s Name + l + v► P 6�'S,:r� �t Phone <br /> Address O o Zt _ .�_ � � ,_ �AmY, City <br /> t G r f . �.; <br /> Contractors Name, .A)+'j 40 4 i4p �, ,.`e ^e_ -�.� - y-- �-License- bne S-,VF- VS-6 <br /> TYPE OF WORK l(Check): NEW WELL /7 DEEPEN '/-7. RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / /: PUMP REPAIR / / PUMP REPLACEMENT /- j_ <br /> r F Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> { SEWAGE DISPOSAL FIELD ,,lecifsSPOOL/SEEPAGE PIT _OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 1. ­---PUBLICDOMESTICWELL <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 I Driven Gauge of Casing <br /> `Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout ; <br /> Disposal I Other tither Information j <br /> Geophysical Surface Seal Installed By: , <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump f'm � a(� r. H.P. ! %'2 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> ,pE&TRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 FINAL INSPECTION. <br /> SIGNED CUP TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> .FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I DATE <br /> ADDITIONAL COMMENTS: JI <br /> PHASE II GROUT INSPECTION P I N INSPECTIO <br /> INSPECTION BY DATE INSPECTION BYA DATE <br /> 5t711 — <br /> . <br /> t E R 1426 Rev. 1-74 1-74 2M <br />