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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._J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LL­�C-77 a <br /> z (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 '1 )O(/-P CENSUS TRACT <br /> Owner's Name X Q2jQ&27.Ad _ Phone Y-35- 1019' <br /> Address 3 '.�7s' I! City <br /> Contractor's Name p License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT _/ � r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES ' PIT PRIVY , <br /> "SEWAGE DISPOSAL FIELD+ r CESSPOOL/SEEPAGE P'I'T OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE _ TYPE OF WEEL 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 <br /> Irrigation 4 Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: I <br /> 3 J/�/ Sta•te '�ark Done <br /> DESTRUCTION OF WELL'A.' We` Diameter <br /> �AF oximate Depth <br /> - � / /C <br /> Describe <br /> — <br /> Material and Procedure \ <br /> 2 ( s o <br /> I hereby agree to comply with all 1a s and regulations of the San Jodquin Local Health District <br /> and the State of C lifornia pertaining to or regulating w_ie11->rcdii ucrion. Within FIFTEEN DAYS <br /> after completion of m raar_.on e11I w:ill�furhish�the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 4- 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> J <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE II / NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -_E x_1426 Rev. - 1-74 "`� 2M <br />