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n �J 3 �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, Calif. � ,��p <br /> - Telephone: (209) 456-67$1 Permit <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> �S r1' <br /> THIS PERMITDate Issued <br /> . EXPIRES 1 YEAR FROM DATE ISSUED �— i <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaed. This°applicational Health District made inra permit compliancetwithnSanuJoaquin <br /> and/or install the work herein described. application <br /> County Ordinance No. 1$52 nda the Rules and Regulations of the San Joae1A1�o/.1141VP District- <br /> County EC,yav1 RO. CENSUS TRACT <br /> JOB 'ADDRESS/LOCATION /�I % / <br /> IJII��fS�'i�/�• Phone <br />� Owner's Name ,E3 <br />} City <br /> �. Address � <br /> Contractor's Name <br /> 97- Lo License # Phone�32—S 2,67 <br /> , TY$E-OF.'.WORK- (Ghe�1F)_: i4EW�WELI�,� STRU <br /> DEEREN. /`PUMP REPAIR/N1/ pUMP�REPLACEMENT��1 F <br /> PUMP INSTALLATION <br /> Other / / <br /> EWER LINES,4G'Cl ' -PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK �� ' ESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD Z 0O 4 PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION� G <br /> Industrial Cable Tool Dia. of Well Excavation f q <br /> Domestic/private Drilled Dia. of Well Casing PVC <br /> -�-- Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal �O <br /> jRotary Type of Grout <br /> Cathodic Protection Other Other Information <br /> G Disposal -' Surface Seal Installed By: Du+�✓�'�- <br /> Geophysical . <br /> ST�Gl7/ E <br /> PUMP INSTALLATION: Contractor TE <br /> Type of Pump <br /> PUMP REPLACEMENT: I / <br /> State Work Done <br /> State Work Done <br /> PUMP ,REPAIR: �/ _ _ ... .. ... e.. w.1 <br /> -�.. pP o ` <br /> e Dep th . <br /> ..l.�. --- _ ....p-;� __ - -� <br /> DESTRUCTION OF WELL: Dell Diameteribe al and Procedure <br /> . <br /> I ith all lams and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply w <br /> and the State of California pertaining to or regulating �i7ell'c°nstruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well Ithemlbeforesputtingh the atheawel]ninouse.cal HeThehaboverict <br /> WELL DRI REPORT of the well, d notify <br /> informa ion i true to the best f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> f PRIOR TO GROU ING D AL I ECT IONa <br /> TITLE <br /> SIGNED <br /> I3EtAW PL T PLAN 'ON RE FRSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> w. <br /> PHAS .� - � ,,� DATE ,-y r7 <br /> E I ''',�. `.. ,,.,., <br /> APPLICATION ACCEPTEI .' f <br /> ADDITIONAL COMMENTS':.; _ p II /F NAL INSPECTIO, <br /> P SEs G OUT INSPEeT-1 " <br /> INSPECTION BY .--- DATE <br /> -ALL <br /> INSPECTION BY f �--DATE `- <br /> [ 376 2M <br /> n TT lL 'Dev 1-74 _. <br />