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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6783. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W _7C I <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued MAY 2/4 3978 <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION " /3-) ZY AllMa-j4r CENSUS TRACT'/ <br /> Owner's Name,,a/L4,57 SH IT11 Phone 4;�O's- <br /> Address <br /> 'Address 'S� (ff'IVf-), City <br /> Contractor's Name ���,7 f /�f Z(1 �'_T License #ZOOS Phone-537-5?A ; <br /> i <br /> TYPE OF WORK (Check)—_-NEr1'WELL-R/' DEEPEN-/- / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION ! PUMP RE AIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK✓� SEWER LINES-/00 PIT PRIVYIr <br /> SEWAGE.,D,ISP.OS jIELD'!�._(,) CESSPOOL/SEEPAGE PIT OTHER �jj <br /> PROPERTY LINE PRIVATE DOMESTIC WELL _Y_ PUBLIC_ D_0_NESTIC_WELL -J. <br /> INTENDED USE TY_PEeGV WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing P VC- /66 <br /> Irrigation Gravel, Pack Depth of Grout Seal ` <br /> Cathodic Protection Rotary Type of Grouty' N`iZ'3j� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 3y:5f.wjzK aT ABM - _ <br /> PUMP INSTALLATION: Contractor Nnf-I-{) E 2 i <br /> Type of Pump SuAk H.P. ' <br /> PUMP REPLACEMENT: m / / State Work Done <br /> PUMP .REPAIR: / j State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 oJPECTION w well, I will furnish- the San Joaquin Local Health District a <br /> WELL DRILL ORT of the wnd notify them before putting the well in use. The above <br /> informati n is t ue to th bef knowledge and belief. I �WILL CALL FOR A GROUT INSPEC ION <br /> PRIOR TO ROUTI G D NAL <br /> SIGNED A MTITLE Gx',�`� <br /> D W Ph T PLANmON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �: �� DATE 'S 4f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 5,1INSPECTION BY DATE -/ 41 <br /> E H 1426 Rev. 1-74 ' <br /> 3/76 2M <br />