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C� �� �d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBrOF �ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-oZ 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 3-75` <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with San Joaquin <br /> -County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local Health District. <br /> {(.:.��o,�,�..-�CrtP•PE�v�ro:c�t,s��r' �s-- Bsd-o <br /> JOB ADDRESS/LOCATION 06 M W %� t CENSUS TRACT <br /> ' <br /> ;I I <br /> f Owner's Name r rS' Phone / <br /> Address /4 G7 City <br /> Contractor's Name License ## J 1.377,1 Phone --W 7( <br /> � F <br /> TYPE OF WORK (Check): ,NEW WELL/� DEEPEN /� RECONDITION /_� DESTRUCTION f� ti <br /> PUMP INSTALLATION / / PUMP REPAIR f / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ('f� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ; <br /> j INTENDED USE `TYPE OF WELL CONSTRUCTION SPECIFICATIONS n <br /> Industrial Cable fool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing m <br /> X--.Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout °• p <br /> Disposal n ''Other Other Information C <br /> -Geophysical � Surface Seal Installed BY: -� <br /> PUMP INSTALLATION: Contractor 40 � - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> w <br /> PUMP',REPAIR: -7 State Work Done sigi-,gmo1.So 9-64rie- vc- <br /> V <br /> DE&T-AUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f 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 knowlrnd and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I CT . <br /> ITL <br /> j SIGNED w. DEW L T PLAN ON FRSE SIDE <br /> FOR DE15ARTMENT USE ONLY <br /> PHASE I J .7r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> 1 µ8 H 1426 Rev. 1-74 1-74 2M <br />