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k>ZSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> 4 Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, '7,/,- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j.., 7L <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ox 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/LOCATIONr' �' 0t AJ CENSUS TRACT <br /> Owner I s Name —A&A e-11 fe1 164094 ,..., ..� Phone <br /> Address () (� (? City �' pGd s <br /> Contractor's Name G • Rll - 42 License ! wphone <br /> TYPE OF WORK (Check): NEW WELL 7 DEEPEN -/7 RECONDITION` /7 f <br /> _ � DESTRUCTION � <br /> PUMP INSTALLATION / PUMP REPAIR /7 P.UMP REPLACEMENT <br /> 'AdOther <br /> DISTANCE TO NEAREST: SEPTIC TANK iQ SEWER LINES PIT PRIVY _ <br /> SEWAGE DI'SPOIELD - }CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY 1,001 PRIVATE DOMESTIC WELL: PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -- - Industrial Cable Tool i-Dia. of Well Excavation op \ <br /> Domestic/private Drilled "Dia. of Well Casi.ag•� <br /> Domes tic ublic Driven ` ' r <br /> IP :Gauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal _ A <br /> Cathodic Protection" Rotar - �" �— <br /> y, 4Type of.Grout A <br /> Disposal Other , ' -Other Information <br /> Geophysical -Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor _ ��,��,(/�w,_-��- <br /> ^ <br /> Type of Pump H.P. ... t <br />' PUMP REPLACEMENT: % State Work Danes <br /> PUMP ',REPAIR: L7 state Work Done <br /> ES-TRUCTION OF WELL: Well Diameter - ..,-._,-. ....,. ...�. r. . . _ . ..-..._ .,.-..,.m.._- .� <br /> _ 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 i <br /> information is true to the-best-of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GRO G D A FINAL INSPECTION - ,r <br /> SIGNED r-. --. , _` . •- ,. _ <br /> TITLE , <br /> W T PLAN ON REVERSE SIDE <br /> PHASE I MR <br /> DEPARTMENT USE ONLY <br /> 1 - <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I S IONPHASE III FINAL INSPECTION <br /> INSPECTION BY U_�J DAT ',74/ INSPECTION BY DATE <br />` -E_H,1426, c i . <br /> Rev:1=74 1-74 2M <br />