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-_l F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7�rjL4� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued �4 ,-4.2-7S" <br /> (Complete In Triplicate) <br /> 4 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 Joaqui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9 , �Q :�.• .,.r CENSUS TRACT <br /> Owner's Name 1,9 W-4 [.-o w-,J_ ZS DA LZ,_ Phone <br /> Address , c d c City c. <br /> z <br /> rf � <br /> Contractor's Name s .�t.t -s . < -*� " -License-!',# pp a Phone <br /> f <br /> f <br /> TYPE 0f',,WORK...-(-Check):,=-NEWrWELL;&DEEPENS/�—RECONDITION""/7—DESTRUCTION"/ 7-- <br /> PUMP INSTALLATION // / PUMP, REPAIR / / PUMP REPLACEMENT <br /> t Other <br /> •. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITS OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELI:'---:—PUBLIC'DOMESTIC WELL V <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation 0 'F <br /> Domestic/private Dri—led . - Dia.. of Well Casing <br /> Domestic/public Driven ,�.- Gauge�of. Casing - <br /> 'Irrigation Gravel Pack � DepthAof Groot Seal �-^�+�V j1 �` <br /> ' Cathodic Protection Rotary ` =-� Type of Grout �, ,�jar V(';,� <br /> I Disposal . Other Other Information <br /> Geophysical t Surface Seal Installed By: <br /> PUMP"INSTALLATION:' Contractor <br /> ` Type of Pump �,�. H.P. <br /> U Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> -PUMP:REPAIR• - --- * x/77__ StateYWork Donees - _ <br /> f ES-TRUCTION OF WELL: Well Diameter 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL_INSPECTION. <br /> w SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I J <br /> F APPLICATION ACCEPTS BY a �� DATE �Z <br /> ADDITIONAL CO _ _- <br /> P , OUT INSPECTIOIT PogE� I FINAL INSPECTION <br /> INSPECTIONBY DATE - S INSPECTI DATE 6 S <br /> a <br /> ~E H 1426 Rev. 1-74 1-74 2M <br />