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it <br /> :. SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` = OAjOFFICE USE: II 1601 E. Hazelton Ave. , Stockton, Calif. ,4 PPPW� <br /> Telephone: (209) 466-6781. <br /> "APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S` 7� Y✓ <br /> i THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued 3-/-j- '7S� <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 /> j County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 66 q7 Al , <br /> JOB ADDRESS/LOCATION C�- ,>( f+ So 1 ld c,,/.::- 94�o-QA-J .P-£ENSUS TRACT - <br /> Owaer's Name J+tl4 G 1 i� Pl-xone 7— �b <br /> Address City . <br /> Contractor's Name ,� License # f YOS-S 2 Phone <br /> TYPE OF WORK-_(Check): ,NEW.WELL--4F DEEPEN /7 RECONDITION• /7— DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% _ PUM! REPLACEMENT 1 <br /> Other /-7 <br /> o � <br /> DISTANCE TO NEAREST: SEPTIC TANK IQ,<�— SEWER LINES 1 2,� PIT PRIVY C) <br /> SEWAGE DISPOSAL FIELD 0 CESSPOOL/SEEPAGE PIT _C OTHER <br /> PROPERTY LINE ,- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE it TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialI _ Cable Tool Dia. of Well Excavation l t <br /> Domestic/private ;; Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing onjiir- <br /> Irrigation Gravel Pack Depth of Grout Seal �Q <br /> Cathodic Protection Rotary Type of Grout _t� �.5,6� / lni'}x <br /> Disposal. Other Other Information <br /> Geophysical. Surface Seal Installed B -- <br /> PUMP INSTALLATION; Contractor ��! J P <br /> �J;/�{,/✓.� . <br /> Type of Pump H.P. x <br /> PUMP REPLACEMENT: 7 / State Work Done <br /> PUMP :REPAIR: State Work Done <br /> E&TRUCTIONTOF"WELL: 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 ore them befputting..the..well in.uae.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> t PRIOR TO UTIG D A41NAL INSPECTION. <br /> SIGNED TITLE yam _ <br /> Q (DRAW PLOT PLAN ON REVERSE SIDEt7 <br /> a PRASE I <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY` DATE �- <br /> ADDITIONAL COMMENTS: <br /> PHASE ITI GROUT INSPECTION PHASE 11gFINNSPECTION <br /> INSPECTION BY DATE 1.5 INSPECTION- BY DATE <br /> �� Lee. �-ls-e-� �►•� <br />' t E H 1426 Rev. 1-74 1--74 2M <br />