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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE�.O F�E 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 'l YEAR FROM DATE ISSUED Date Issued -4-�-77 <br /> (Complete In Triplicate) <br /> Application i8. 'Aereby 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 /> County Ordinance No. -18_62 and the RjAles #nd Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB "DRESS/LOCATION. -3� uma CENSUS TRACT <br /> Owner's Name {L� �l�.Q R aiaa�44J' - -,Phone <br /> Address ,- City ' . <br /> ..,�., <br /> Contractor's Name (A _.License #c�ftVl, Phone�:JJ <br /> - i <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN I�I RECONDITION /�?DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / `PUMP REPLACEMENT " <br /> Other 1 <br /> DISTANCE.TO NEAREST: SEPTIC TANK f SEWER LINES go PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION �• <br /> Industria. Cable Tool Dia, of Well Excavation " 4\ <br /> t <br /> Domesttc/private Drilled Dia. of Well Casing -�:�� T - -Ail <br /> Domestic/public—. -Dr-i-ven.� Gauge of Casing <br /> `� Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. , Rotary Type of Grout <br /> 7 Dispasa'l Other Other Information VC <br /> Geophysical Surface Seal Installed By: <br /> PAIT. INSTALLATION: Contractor '" -, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> { PUMP .REPAI , / State Work Done <br /> } DES-TRUC WELL:- Well Diameter Approximate Depth <br /> D ribe Ma eri I and iocedure: <br /> I hereby agree to comply with all, laws Old regulations of the San J quip Local Wealth District . <br /> land, the State of California pertaining to or regulating well `nnnst uction. Within FIFTEEN DAYS <br /> after completion of r4y work on a new well, I 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 INSPECTIOIj <br /> PRIOR TO GROUTING AND A�,FINAL INSPECTION. <br /> SIGNED 1 QQ 1 ems.' �� J ✓ Ia�ITLE - -7Z <br /> W PLOT PLAN ON REV SE SIDE <br /> FOR DFPARTMENT USE ONLY <br /> t'PHASE I ' <br /> , APPLICATION ACCEPTED BY f DATE . <br /> ADDITIONAL COMMENTS <br /> PHA II ROUT INSPECT O PHAS I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />