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i <br /> �.: SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Ilssued ��7?�- <br /> (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 ' ith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION �JC_Y 07k)D CENSUS TRAICI T . <br /> Owner's Name JC d Phone , ?3 <br /> 3 " ! �, <br /> Address f City <br /> Contractor's Name OLOPV UtLL 4z ��`(� License [�b�� Phole ` ,Q-5'5_ <br /> TYPE OF WORK (Check): NEW WELL -/ DEEPEN '/_7 RECONDITION /_7 DESTRUCTION # <br /> PUMP INST�LATION 7PUMP REPAIR /� PUMP REPLACEMENx /7i1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK LIL)_ SEWER LINES - PIT PRIVY ^ i <br /> SEWAGE DISPOSAL FIELD=---CESSPOOL/SEEPAGE PIT OTHER r I <br /> PROPERTY DINE - PRIVATE, DOME$TIG 'WELL '=- PUBLIC DOMESTIC WELL <br /> INTENDED USE r TYPE OF'WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial � ! Cable'Tool Dia:of"We11~Excavation /40 1M <br /> Domestic/private DrilledDia. of-Well Casing- 'Co ij <br /> Domestic/public i 1 }Dri�isn .-,Gauge_of Casing <br /> Irrigation Gravel Pack F D'epth'of Grout Seal <br /> Cathodic Protection s :'"Rotary -�` - <br /> *� :Type f;Grout l f k <br /> Disposal Other v� Oth' r 'Information j <br /> Geophysical. � � Surface Seal Installed B : 0 7W E 2� <br /> t f <br /> PUMP INST�ALLATIflNa Contractor <br /> Type of`_P.ump` 1 <br /> H.P. <br /> PUMP REPLACEMENT V-,'- �,J,./. /�__State jWork Done <br /> PUMP -REPAIR: % / State=Work'.Done` � <br /> DESTRUCTION OF WELL: �f <br /> Welt Diameter ,.Approxiidatie Depth <br /> Describe Material and Procedure . J� <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 anew well, I will furnish the San Joaquin Local Health District a i <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 />?RIOR TO I 'AND A FINAL INSPECTION. <br /> SIGNER TITLE f <br /> G (DRAW PLOT PLAN ON REVERSE SID �M <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,iZ <br /> ADDITIONAL COMMENTS: <br /> P E IIII OUT 'INSPECTION �r PHASE I FINAL INSPECTION <br /> INSPECTION BY -z DATE INSPECTION BY DATE C - <br /> E A 142E Rev. 1--74 _ :. r'` ._ � !,/�co,u <br />