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SAN JOAQt31-�- AL HEALTH DISTRICT i <br /> FOR OFFICE USE: /160' 1 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a-,77,jFtd <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 /> JOB ADDRESS/LOCATION 1660_-- }u, sae, ;2-0?: 2­2!-ol0 CENSUS TRACT } <br /> Owner's rl Name Phone ,..,,. .,_:.,.. .:_. phone P?0 <br /> Address City _ <br /> �� gFL SSS <br /> Contractor's Name License # 1,20�kk Phone , J?3k 7/_'20 <br /> TYPE OF WORK (Check): NEW WELL J DEEPEN/7 RECONDITION­/7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR-/-7 PUMP REPLACEMENT /7 <br /> Other <br /> Ll <br /> k <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PTT. PRIVY ` . s <br /> SEWAGE DISPOSAL FIELD -CESSPOOLJSEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTI_C_VELL_ `'`- PUBLIC_D014ESTIC_WELI <br /> INTENDED USE; TYPE OF WELL _.CONSTRUCTION SPECIFICATIONS <br /> Industrial )e :Cable-Tool Dia. of Well Excavation <br /> Domestic/private FDrilled Dia. 'of WeCasing,__- <br /> Domesticpubf <br /> _ /4 <br /> /p l is �. _Driven .Gauge of Casing <br /> Irrigation •f . ;Graved Pick" Depth of Grout.Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal f ° Other Other Information, <br /> Geophysical . ,Curf.ace Seal nstalled 'By, X44tA,nowe <br /> PUMP INSTALLATION: C ntracto » <br /> Type of, Pump �. 'S .. H.P. <br /> PUMP' REPLACEMENT:-""'"­/ J" State Work Done <br /> fi <br /> PUMP.REPAIR-.- -State work Done <br /> w : <br /> DESTRUCTION OF WELL: Well Diam;'ter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to .comply:-with all laws and regulations of.the San Joaquin Local 'Healtli District <br /> and the State of California pertaihingwto or regulatirig.;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 j <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 F'INAL 'INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I4) <br /> APPLICATION' ACCE_P B _ _ _._DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - - PRS II AI. -INSPECTION;:' <br /> INSPECTION BY DATE INSPECTION BY,, DATE <br /> _ ,H-1426 . Rev. 1-74 <br /> /P-/.. r�c P 2M <br /> _ l <br />