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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. C <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,. , JJI <br /> i <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date. Issue-d <br /> (Complete In Triplicate) <br /> Application is here made to the San Joaquin Local Health District for a permit to construct <br /> sand/or install the work herein described. This application is made in compliance with San Joaquin4 <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health 'District. <br /> JOB ADDRESS/LOCATION v`� S �7-� r Cjo(.) ),` 4�XC,M-(QENSUS TRACT <br /> Owner's Name Phone S3Jf-32 o Z <br /> Address S city. <br />' Contra c or's Name License ���`1 dV3Phone r4�'llkj <br />' � - <br /> fL <br /> TYPE OF VWORKheck) : EW WELL ./ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> WT__ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other I <br /> / J _ — <br /> t , <br /> DISTANCE 'TO N AREST: SEPTIC TANK SEWtR LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Ci <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �oinestic/private Drilled Tia. of Well Casingp,j.pSflC__ <br />? D"emestic/public Driven Gauge of Casing v,4G C— <br /> Ix;Tigation Grave]_ Pack._ -C:Deth of Grout Sealj <br /> Cathodic Protection .K Rotary .-Type of Grout 5AAi70wi-74t <br /> -'Disposal Other Other Information _ SC_RG— `; pct n1_ r <br /> /-,7 Geophysical Surface Seal Installed By : h ' <br /> PUMPJINSTALLATION: Contractor 0WA46X <br /> i r Type of Pump H.P. ' 3 <br /> PUMA' RE! LACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ° . <br /> _ _ k. <br /> Nt <br /> DESTRUCTION OF WELL: Well Diameter," �; '"3 . F Approximate Depth <br /> ■ <br /> De.st--r, bi MaterYal:and PKQ6 duce _-- <br /> I hereby agree to comply with all laws and regulA,,idn' -%of L'Whe San Joaquin Local Health District <br /> and the State of California pertaining to or regul t ng-kwell "construction. Within FIFTEEN DAYS <br /> after completion of my work .,on a new well, JIwill furnish the San Joaquin Local Health District a <br />; WELL DRILLERS REPORT of the well and notify tembefore putting the well in use... The above- <br /> informa&on is true to the best of- my knowltedge' and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOIG UTING AN FINAL INSPECTION. f <br /> SIGNED TITLE S ' <br /> (DRAW PLOT,PL"_AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - - --7 <br /> ''] <br /> APPLICATION ACCEPTED BY r/" � DATE. I � <br /> �l a' <br /> ADDITION COMMENTS': <br /> PHASE II GROUTjNSPECTION P� -:-PHASE IIJ/FIN4 II /FININSPECTION <br /> INSPECTION BY DATE: IN-SPECTION BY/ DATE V— 7'1 <br /> F <br /> E.- -'E :.H.-1426 Rev 1-74 �I��.S�� W��, �1A A / °, - a <br />