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t <br /> f") SAN JOAQ.UIN LOCAL HEALTH. DISTRICT <br /> FOP-,OFFI•CE `USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -2�g- Zgp� <br /> We&-; 11ojer,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 herein described. This application is made in compliance with San Joaquin <br /> F County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � 1 <br /> � <br /> ' a Q SCJ CENSUS TJOB ADDRESS/LOCATION TRACT <br /> Owner's Name Phone -Pd <br /> Address k--V Cr city <br /> p <br /> Contractor's Name License 'CVad OPhone 'LS-D--;�'&31 <br /> Yw TYPE OF WORK (Check) : NEW WELL � DEEPEN/ / RECONDITION 17 DESTRUCTION <br /> PUMP INSTALLATION / -/ PUMP REPAIR / /- PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/2&.` SEWER LINES PIT PRIVY <br /> SEWAGE DIS OSAL 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 _ /� <br /> ,A/Domesti'c/private /Drilled Dia. of Well Casing <br /> Domestic/public Driven , Gauge of Casing /.:P— <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Otlier Other Information <br /> Geophysical ,_ '" Surface Seal Installed By: AL! -e <br /> PUMP INSTALLATION: Contractor f <br /> Type of. Pump H.P. <br /> . C <br /> PUMP REPLACEMENT: ' / / A State 'Work*Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mate is and Procedure <br /> I here agre�to o ly wi all aws and regulatio s of the�San3oaqui 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, ] 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 FIN LN CTION. - <br /> i SIGNED TITLE , 4 <br /> PLAN ON REVERSE SIDE <br /> OR, DEPARTMENT USE ONLY <br /> PHASE-I------ --- :f _ .� - <br /> .r."..,�.�'." f ...fir--.-+�w}.h..rs!�—ir +•'.r's.p..-r.w <br /> APPLICATION ACCEPTED BY f ;DATE <br /> ADDITIONAL-COMMENTSi._� - / <br /> PHASE II GROUT INSPECTION PHASE III/FINAL IN.SEECTION <br /> INSPECTION BY DATE INSPECT ON BYDATE <br /> 3/7 2M <br /> E H 1426 'Roe val <br /> ev. 1-74 -� <br /> i - Ar - - <br />