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f <br /> 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE' ISSUED Date Issued���p <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Districtf.or 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 .�]c �,� .��� CENSUS TRACT ' <br /> IOwner's Name Phone v���? -- 7 A L�.�.%qtr - -- <br /> Address ) m T^� City 's'; <br /> Contractor's Name r ( D 1S.A� ]yy/ License #2ff <br /> Phone-ARA40 7 <br /> TYPE OF WORK (Check) : NEW WELL / tt_'" tEPENJ/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / J.� REP.AIR^/ ?UMP_RF,.P-LACEMENT / % <br /> y Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -1 <br /> PROPERTY LINE - PRIVATE DOMESTIC:WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, ofl-_ e 1 Excavation <br /> Domestic/private Drilled Dia. of•,Well Casing 5 <br /> Domestic/public Driven Gauge o'f Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> E Cathodic Protect'i'on E R`o`tary Type of Grout <br /> Disposal _ _ 1 .- _O-ther.. ___ . _ Othe .Inf.cirxnation <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: i Contractor --- <br /> Type of Pump ; H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work. Done �Qt�-► ti 4 <br /> DESTRUCTION OF WELL: '. Well Diameter . Appr.oximA Depth t <br /> I?�e riVe_Material. and Procedure ' x <br /> ��..-T ,� �� t __, mow- •., -• W. ;��'M , <br /> I hereby agree to comply with -all laws and regulations of the San Joag4in L616al ,Hdalthi0strict <br /> and. the State of California pertaining to or regulating well -construction. \Withi-n FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San 'Joaquii 'Lecal health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting- the well' in rise. -The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> } PRIOR TO GROUT^G AND WIINSPECTION. ,.. - <br /> SIGNED ^# TITLE � • <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED EY i7,f s.;�C'r� .'` DATE .� <br /> ADDITIONAL COMMENTS: <br /> PHASE,;:I'I_�, ROU -.INSPECTION PHASE,,III/FINa INSPECTION r <br /> INSPECTION BY ,.s 'l] TE. ._, INSPECTION BYjV DATE <br /> P T-i T G 99 n o„ 1_74 <br /> 6/77 _ 2M <br />