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SAN JOAQUIN LOCAL HEALTH DISTI��FCT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, %Calif. <br /> Telephone : •(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .a_37 3 LJ <br /> • k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 with 'San Joaquin <br /> County Ordinance No. .,1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Z"!e F3 2- ---�'.. r-,; 6:pp: ff� A-!>I-) � 2-Y 7-r'7-a---vp ' <br /> JOB ADDRESS/LOCATION r��G`LfA�p C71�.�r91 �7�.Ia�E1S ( - S[TS TRACT <br /> Owner's Name C<�J2Q � h�IGL�� ���G Phone ,3,?^ZlIJ j <br /> Address _ I X16 City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/_/ RECONDITION /_/ ' DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other 17 <br /> `. --- <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 <br /> Domestic/public Driven Gauge of Casing A& Cir <br /> -- Irrigation j/ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection A_ Rotary Type of Grout <br /> 4.- Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: j <br /> PIJMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / ' State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> a <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 G UTING ANDA FINAL IN EGTI N. <br /> SIGNED ITLE <br /> ff <br /> (DR.(DR4W PLOT PLAN 'ON REV E SIDE <br /> FOR ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE �p <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROU . INSP.ECTION P NAL INSPECT N <br /> INSPECTION BY DATE INSPECTION DATE pj rI <br /> /376 <br /> t ' v 3 7 <br /> H 1426 Rev.- l-74' fi 2M <br />