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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> 'F0 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR 'WELL-CONSTRUCTION OR PUMP PERMIT Permit No. Sly 917 <br /> 77, - 6,3. <br /> f° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <br /> r' (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 /> "County4rdinance No. 1862 and the Rules and Regulations of the San Joaquin Local ,Health District. <br /># 'JOB ADDRESSfhee*ft6N ,l��� CENSUS TRACT <br /> Owner's Namey tt /! ? Phone <br /> Address City <br /> Contractor's Name GS 'Y $ U{/� License� PhaneQ ��Z/f1 i <br /> ,i <br /> i <br /> i <br /> TYPE OF WORK (Check) :, NEW WELL DEEPEN%/ RECONDITION / / DESTRUCTION /_ ? <br /> PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES /040-e--PIT PRIVY <br /> SEWAGE DISP Sj ELD CESSPOOL/SEEPAGE PIT - OTHER <br /> F PROPERTY LINF -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL t- <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 t <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> i` Disposal Other Other Information ' <br /> Geophysical Surface Seal_Installed By: ,a - <br /> t PUMP INSTALLATION: Contractor 9) '2Wg'1 <br /> Type of Pump ` <br /> PUMP"REPLACEMENT: _ <br /> State Work Done . '�- . <br /> p PUMP .REPAIR: /�/ State Work Done " �4 4 <br /> I° DESTRUCTION OF WELL: Well Diameter f 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. 1. WILL CALL FOR A GROUT INSPECTION <br />'E PRIOR-TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED 6uV- <br /> t_ _ <br /> W 1 T_ LAN N -RE E-RSE.-SIDE _* i._ <br /> FOR . PARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE <br /> tip <br /> ADDITIONAL COMMENTS: :: 4E� 1Z <br /> T" N PECTION- PHA INSPECTION .. <br /> INSPECTION BY DATE Z INSPECTION BY DATE <br /> r <br /> jel <br /> 3/76 2M <br /> E H 1426 Rev: 1-74 <br />