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�"= w SAN JOAQUIN- LOCAL .:HEALTH DISTRICT <br /> FOF ']FFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L/ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /o- -77 ; <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 hprein :described. This .ap plication is made in compliance with San Joaquin; <br /> County Ordinance ;No. ,1862 and the Rules anti. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . Ste . �.� L L p CENSUS TRACT, <br /> Owner's Name <br /> ---- - - _-�� �' Phone <br /> Address Li'. . <br /> Contractor's Name I✓ A/r IJfS^S LLI"-CaT icense # gD�l3 Phone S-4S'- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z�Oa ! SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation d _ <br /> Domestic/private Drilled Dia, of Well Casing (n-&7-f G <br /> Domestic/public Driven Gauge of Casing � j� Y} co r?LL- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout E6,vr"a K,, T`� "t <br /> Disposal Other Other Information �( � <br /> Geophysical ;. Surface Seal Installed By : p al c E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DES•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 /> aftercompletion of my work on- a nein well, I will furnish the San Joaquin. Local Health District <br /> WELL DRILLERS REPORT`of`'the"well and notify them before putting the well in use... The above <br /> information is true to the b t of my knowledge and beli-ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROIdING AND SIN I)ISPECTION. j`= o5 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY t DATE ---� <br /> ADDITIONAL COMMENTS: 99 4izm r ' <br /> PHASE II GOUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY 4X­�DATE 2-;7 INSPECTION BY DATE ZL �i <br /> E H 1426 • Rev. . 1-74 6, 77 _ 2M <br />