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t <br /> . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 31S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> ,•�S r - .� ��k (Complete in Triplicate) �� bSj w Zoa (� <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 wade in compliance with San Joaquin, <br /> County Ordinance No. V62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO z W4 4 ! SUS TRACT <br /> Owner's Name /�,�� A 0 4�. Phone ; J `' <br /> Address . M® ,_A-4 954 AL C 1`® Al City <br /> Contractor's Name _ Q License , ,Phone . <br /> TYPE OF WORK (Check): NEW WELL/ ' DEEPEN / / RECONDITION, /7 DESTRUCTION f7 <br /> is <br /> L, PUMP INSTALLATION / -PUi�? REPATR­/,`/-. PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6 SEWER LINES / ! wFIT PRIVY �] <br /> SEWAGE DISPOSAL FIELD /1 .. :,CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DGMESTIC"WELL PUBLIC DOMESTIC WELL IT) <br /> : INTENDED USE TYPE-OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , i/" Cable Tool Dia. of Well Excavation <br /> 1 a" <br /> Domestic/private Drilled Dia. of Well Casing i <br /> t Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack A Depth of Grout,Seal <br /> Cathodic Protection Rotary Type of Grout VAkA <br /> t Disposal Other Other Information <br /> a Geophysical Surface Seal Installed B <br /> t f° <br /> PUMP .INSTALLATION., Contractor <br /> Type of Pump �i1f/ ,j -- H.P. _. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /'7 State Work Done -. �. <br /> 4ES;TRUCTION'6F_ 'WELL: Well Diameter F`'rt Approximate Depth <br /> Describe Material and Procddite.-. f <br /> 1 hereby agree to comply with M-laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or*`regulating weil 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish tlie`° 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 ttie-best of my knowledge and belief. I WILL _CALL FOR A'GROUT_INSPECTION <br /> PRIOR TO GROUjjNG .AND A FIN PECTION. <br /> SIGNED "y Y TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID_ —~ <br /> FOR.DEPARTMENT USE.-ONLY <br /> �- <br /> PHASE I - <br /> APPLICATION ACCEPTED_BY ^"" „' = DATE <br /> ADDITIONAL COMMENTS: <br /> :. PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> 7'.'�.EECTION BY L.. - DATE -.r.7>� -INSPECTION BY DATE 6 <br /> . : <br /> Rev,-1-74 ., 1-74 2M ail <br />