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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.: FFIC USE: 1601 E. 'Hazeltom:Ave. , Stockton, Calif. <br /> yyy Telephone: (203) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S_-_�VA1 <br /> THIS PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued <br /> U� (Complete In Triplicate) <br /> ,Application is hereby made to the San Joaquln .Local Health District for a permit to construct <br /> andJor. install ..the work herein-described.,zi,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 /> AJ �A-r��P,�c /z-�1 n�: CC (o--C+a O-2_y <br /> :TOB ADDRESS/LOCATION s� Q �,/� s.�, /� ,' ',GC CENSUS TRACT ai <br /> + i . <br /> Owner`s Name dl w so Phone <br /> Address �f O 742 ,/. oa^ City �'� <br /> Contractor's Name zzlory .. License /g3-7y3 Phone 9192: 7,e7j�f <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN /_7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION ,/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / kip& _gcecV----_., <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 i <br /> Domestic/public Driven Gauge of Casing <br /> 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 d 6 H.P. <br /> PUMP REPLACEMENT: j_/ * State Work Done <br /> PUMP!3.tEPAIR: State Work Done rit 12,tce - J'� � '02 0,011;i/ <br /> 4ES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby Agreetocomply 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 /> E information is true to the-best of my knowledge and belief. I WI L FOR A ' OUT--INSPECTION <br /> PRIOR TOG U ING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> k DRAW PLOT PLAN ON REVERSE SIDE' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I [. <br /> APPLICATION ACCEPTED BY DATE `�� <br /> ADDITIONAL COMMENTS: <br /> F PHASE II GROUT INSPECTION PHASE IFI NSPECTIO <br /> INSPECTION BY DATE INSPECTION BY TE <br /> f . E H 1426 Rev. 1-74 1-74 2M <br />