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t SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave'. , .Stockton, Calif.- <br /> Telephone: :` (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -S76t11 <br /> ai _ 1 .;7,7—ya p <br /> THIS 'PERMIT EXPIRES111F YEAR FROM' DATE ':ISSUED T ;Date Issued L-4-2,2,: <br /> (Complete In Triplicate,) <br /> Application is =hereby made to the San Joaquin',I 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 7_ ;L O p0 s Cd HCl: GC.DGtJ I0p CENSUS TRACT , <br /> r � <br /> A �' <br /> Owner's Name J C <br /> ✓� [��G u AJ � Phone �[ 3-_�'�0.49„_ <br /> Address ZA l - <br /> f <br /> city Z l u�r2�td 467 <br /> Contractor's Name L ' License # 2_719?.C�Phone C37-^S101 <br /> 3 <br />,TYPE OF WORK (Check) : NEW WELL p JL. DEEPEN ,/ ;/ RECONDITION / 7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / ./ PUMP REPLACEMENT / <br /> Other <br />`DISTANCE- TO NEAREST: SEPTIC TANK //O-/ SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ij CESSPOOL/'SEEPAGE PIT 10THER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO <br /> Industrial Cable Tool Dia, of Well Excavation <br /> omestic/privateyVrilled Dia, o£ W asing <br /> Domestic/public Driven Gauge of A- foo <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout /z& _ g�q <br /> Disposal Other i Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: f Contractor NAJL"V�� <br /> 4. Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP'REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL `. ' 'Well Diameter i Approximate Depth <br /> Describe Material and Procedure <br /> d� <br /> I hereby agree to comply =wi.th 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 complefion of my work on a new well, I will furnish the San Joaquin Local Health District' a t <br /> WELL -DRILLERS REPORT- of the well and notify thJm 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 GRQUTLNG AND A FINAL INSPE ION. <br /> SIGNED L TITLE <br /> (DMLOTGPLAN ON REVERSE SIDE) _ U <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e4 are,z DATE <br /> �:_. - <br /> ADDITIONAL COMMENTS: if - <br /> PHASE II GROUT INSPECTION I PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 T 1177 _ 2M <br />