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�.�. <br /> f SAN JOAQUIN LOCAL. .HEALTH DISTRICT off' <br /> FOH OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781''`- .­- • L/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Permit No. 7 <br /> k THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //'f <br /> (Complete In Triplicate) <br /> t 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 incompliance with San Joaquin <br /> County Ordinance No. 1$ a d the ules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION �� <br /> �/J . ® ��� CENSUS TRACT <br /> Owner's Name / /�/�� �7L' V j6p,&0e). Phone�� ' c7f_�0 <br /> Address. / /� ?D -D City 2Awe;* IMP <br /> Contractor's Name License/P-913 Ph'3n�6 �rj <br /> 'TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION /_ DESTRUCTION r7 <br /> PUMP INSTALLATION'/_/ POMP"REPAIR %// PUMP REPLACEMENT <br /> Other` /- // <br /> DISTANCE TO NEAREST: SEPTIC-TANK r SEWER LINES SPIT PRIVY E <br /> 9SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF -WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> �Domesticf-private Drilled , .Dia, of Well Casing q <br /> - ` Domestic/public Driven- ;* Gauge of Casing a_ <br /> Irrigation Gravel Pack` Depth of Grout.S "- <br /> Cathodic Protection 1____�Rotaryer Type Oth' of Grout / <br /> Disposal Oth4 ' <br /> h ver Information <br /> -:Geophysical :, :* k a ' � _5txrface Sealz.Installed By: <br /> CZ-1/0197 F <br /> *' P� <br /> PUMP INSTALLATION: ��'Contractark <br /> * Type of. Pump <br /> ' 1 <br /> PUMP REPLACEMENT: , ' / State Work Don <br /> PUMP .REPAIR.: <br /> _ State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depot <br /> 1' Describe Material and Procedure <br /> I hereby agree to comply with all laws <br /> t Y and regulations of the San Joaquin Local Health bistrict <br /> and the State of California pertaining to or-regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my 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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED <br /> J, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYC' DATE .1� .�-,77 <br /> ADDITIONAL COMMENTS: y-7 Cl�cd c� c ,. <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPEC ION <br /> INSPECTION By "' ,)° DATE /1-/y" 7 INSPECTION BY DATE <br /> J <br /> Rev. <br /> E H 1426 1-741 ����� �� , 1177 _ 2M <br />