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/ SAN JOAQUIN LOCAL� HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E., Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /l 3 Grp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' -X11 -77 <br /> (Complete In Triplicate) <br /> F 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 an the Rules and Regulatio of e San Joa L cal Heal.t�hlDrict. <br /> dc's S S - r dal- <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ' a Phone <br /> Address _w C City _ <br /> -� <br /> cm ALZA_ <br /> � , �,. �,b . nse• #.. b_Phone5'C1�-63� <br /> Contractor`s"Name' <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN { / RECONDITION / / DESTRUCTION /? <br /> PUMP INSTALLATION ... . REPAIR / / PUMP REPLACEMENT /_7 <br /> Other- / <br /> DISTANCE TO NEAREST: SEPTIC TANK, �EWER'LI-YES-���iT PRIVY <br /> SEWAGE DISPO�IELD () 1.l ESS POOL/SEEP�GE PIT .OTHER <br /> PROPERTY tLINE—PRIVATE DOMESTIC WELL 20 PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> adjadustrial `t.; Cable Tool Dia, of Well Excavation. <br /> estic/private Drilled Dia. of Well Casing <br /> Domestic/public Dri'Ven Gauge of Casing <br /> � I-trigs=tiBnT 4-,;_, �..Y. _Gr e1 Pack Depth of Grout. Se <br /> Cathodic Protect- yRatarY- 4 `" Type 4:f-Grout =- - t <br /> Disposal ` 'Other `"'" " Other Informatinn � y <br /> Geophysical �;� ,;'- '''" A- Sur Seal Inst <br /> ' alledLB <br /> r <br /> PUMP�INSTALLATION Contiactor <br /> �pe of., Pum <br /> T <br /> PUMP REPLACEMENT: / '/w State Work Done ` <br /> F PUMP-.REPAIR: S:ta:t ork ,Done. <br /> r DESTRUCTION OF WELL: Well=�i.aineter Appro imate Depth c�'Q <br /> P Describe ter 1 and Procedure <br /> i I hereby agree to comply Werth all laws afid 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 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 put'1ing the well"' in use. The above <br /> in tion is true to the best knowledge and belief. I WILL CALL FOR A#GROUT INSPECTION <br /> PRID D OUTING .AND A F N T N, <br /> SIGNED TITLE <br /> W P1 PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCE - VH-(-lhlD DATE <br /> ADDITIONAL COMMENTS: k <br /> P I OUT INSPECTIO PH4W, II IAL INSPECT ON <br /> r INSPECTION BYDATE 0 `; INSPECTION B DATE <br /> � r <br /> 3/76 2M <br /> E H 1426 Rev. 1-74/ �- �� elG `,. <br />