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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk.�JFF-Ia USE: 1601 E. Hazelton .Ave. , Stockton, Calif. j <br /> Telephone: (209) 466-6781 J , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ���7d ', <br /> THIS PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED. Date. Issued <br /> t (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 C.arrc• Bnb/ e ,Uj,. 7`f SS'.rlCENSUS TRACT <br /> Owner <br /> ` o.s Name it 10 e, V,I IV, Nv.� Phone qzYtf-,2 2_9I _ <br /> Address :ell12 City. <br /> Contractor's Name YL' d a ��r License # Phone <br /> ,TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP 'INSTALLATIONL/ / PUMP REP IR / / PUMP REPLACEMENT /-7 : <br /> Other 's T , ✓ e'n Y' + —?iykXAroa �yPVPs7i c�/O�t Y �I^ c�er3 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY j. <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 Q._ <br /> Industrial able Tool Dia. of Well Excavation 2 <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection Rotary Type of Grout re e.-#- a,, e-,&'�jhe - _-- <br /> gisposal " Other Other Information <br /> eophysical Surface Seal Installed B <br /> RUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' ; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REP.AIR: / / 'State Work Done - <br /> I <br /> DES-TRUCTION OF WELL: Well Diameter 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 <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 TITLE �srac •�iz�4e ceo.. Cera <br /> 4 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FPR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 12-1171-77 <br /> ADDITIONAL COMMENTS: <br /> PHAS I GRO INSPECTI N P S I/FIN INSPECTION r <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> iD'�7 <br /> E H 1426 Rev. - 1-74 4 <br />