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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0T:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _2 V pk <br /> THIS PERMIT EXPIRES' l 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 ie.. made ,in,:cornpliance with -San 'Joaquin <br /> County Ordinance N6. '1_862 and the Rules nd Regulations of the San Joaquin•Local Health° District. <br /> 4jA-t- i,� <br /> JOB ADDRESS/LOCATION CENSUS° TRACT <br /> Owner's Name1k ryl 192ti <br /> 4 .. <br /> Phone ,=— <br /> Address <br /> Contractor's Name _T- D, S5:;�6,1 .� SOA) ' License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION %f� T - . <br /> : PUMP INSTALLATION Ll PUMP_ REPAIR ? PUMP REPLACEMENT f <br /> ` Other / / <br /> DISTANCE TO NEAREST: t SEPTIC TANK SErtJERsLINES " FIT PRIVY <br /> .SEWAGE DISPOSAL FIELDS -;, CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL` <br /> INTENDED USE TYPE OF WELL,t+ _ CONSTRUCTION SPECIFICATIONS <br /> Industrial. 4 :. Cable Tao1 � Dia. of Well Excavation <br /> Domestic/private Drilled <r'" Dia. of Well�Casing:" " <br /> Domestic/public Driven j� Gauge of Casing <br /> Irrigation._ __y_..o.r._. Gravel-.-Pack--Depth-of-Grout-Se'al�`" . <br /> Cathodic Protection ! Rotary - ',.Type=of Grout <br /> Disposal t Other ' Other Informations u. E <br /> Geophysicalr Surface Seal Installed By i <br /> PUMP INSTALLATIONS Contractor.117 <br /> r J. Type .of Pump 3l H.P. <br /> r <br /> PUMP REPLACEMENT: . ? Ll State Work Done ..� <br /> PUMP ,REPAIR: 3 r State Work Done Y - <br /> DESTRUCTION OF WELL: I -Well Diameter Approximate Depth <br /> " Describe Material and Procedure <br /> to <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 oftmy work on a new wel7,, _I_willfurnish the San Joaquin Local Health District a t <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 GROUT INSPECTION <br /> PRIOR TO GR TIN AND AL INSPECTION., <br /> . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE ST <br /> DE <br /> OR E ARTMENT SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT Vi9/--I/V 07-1 DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASMIPAII NAT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Rein. '1_-'74 ' <br /> 9M <br />