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SAN iOAQU <br /> IN LOCAL HEALTH DISTRICT <br /> FWZFFICE USE: i601 E. Hazelton Ave. , Stockton, Calif. 4, <br /> Telephone: (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�i., 9�{pccl <br /> k r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5=rf <br /> j (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health .Diatiict for a pe=it 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_ a1714'_ - 5 CENSUS -TRACT <br /> Owner's Nam r ? a1f_„.�Iv�Til' Phone � -2-331 <br /> Address e t - City <br /> . Y <br /> Contractor's Name5 k -� License .a�l p Phone- <br /> -_ .� 3 - <br /> F <br /> TYPE OF WORK (Check): NEW WELL '/;7' DEEPEN/? RECONDITION / DESTRUCTION /-T <br /> PUMP INSTALLATION / j PUMP REPAIR 1_7­PUMP REPLACEMENT /7 <br /> Other/f , <br /> Q� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT '' OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well. Casing <br /> :r Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection i `/ Rotary Type`%f Grout 1 <br /> Disposal Other Other Information ' LZA - U a,_-ZLC­j <br /> Geophysical <br /> _ _. � ,- _ Suif ace Seal Installed y: �_s-- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , C1 State Work Done _ <br /> PUMPwREPAIR: L7 State Work Done ` <br /> ESMUCTION OF WELL: Well Diameter Appro4imate 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 FORA GROUT INSPECTION <br /> PRIOR TO ROUTING AND F AL INSPECTION. <br /> SIGNED6.44 44 TITLE <br /> DRA T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE <br />,,ADDITIONAL COMMENTS: - AW n p A — <br /> P SE I GROUT INSPECTION PH4SY, I FINAL INSPECTION <br /> E INSPECTION BY DATE wl-S INSPECTION BY DATE <br /> '` E H 1426 Rev. 1-74 1-74 2M <br />