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EE K � ■V/ � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> fFOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stiockton, Calif. <br /> Telephone:p (249) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued )2,,2,p- $r <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 Joaquit <br /> County Ordinance No. 1862 and the' Rules ndgulatione rthe San Joaquin Local Health. District. <br /> �� Z� Aptj 1-0 <br /> JOB ADDRESS/LOC TIONQ• S "YG►'i� 2t, CENSUS TRACT <br /> Owner's Name "� . Phone ' Ste, <br /> �I <br /> Address 3 3 Z A/: S t,�77n�ff . City rn C,W � <br /> i Contractor's Name License # ItI 2:U-Phone''d - 79 <br /> TYPE OF WORK, (Check) : 'NEW WELL _ <br /> DEEPEN /? RECONDITION /_7 DESTRUCTION /7 <br /> ;PUMP INSTALLATION/ / PUMP REPAIR /_7 PUMP REPLACEMENT f <br /> Other <br /> -� <br /> DISTANCE TO'NEAREST: SEPTIC TANK 2_00 of SEWER LINES . FIT PRIVY <br /> SEWAGE DISPOSAL <br /> FIELD CESSPOOL/S EPAGE PI �_ OTHER <br /> PROPERTY LTNE rPRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF W LLCONSTRUCTION SPECIFICATIONS <br /> _ Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private , Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' 0 / <br /> Irrigation � ' Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection _ Rotary Type of Groutj� ��-�-- <br /> Disposal Other Other Information — ,� r,.2cA,14& t <br /> Geophysical Surface Seal Installed B 4&)441•A7C- <br /> PUMP INSTALLATION: Contractor <br /> a Type of Pump H•P. �) <br /> PUMP REPLACEMENT: . <br /> / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: (Well Diameter <br /> 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 /> rand 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:Ithe well and notify them before putting. the..well. in use... The above <br /> information is true Cg the.best-of m ..knowledge and belief. I WILL CALL -FORA GROUT INSPECTION <br /> PRIOR.TO GRDUTIN' � AI;F NAL INSPE ION. <br /> TITLE ,.. <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> x I <br /> PHASE I R DEP TMENT USE ONLY <br /> .J. , <br /> APPLICA <br /> TTOI3 ACCEPTED BY 1, DATE <br /> t <br /> ADDITIONAL <br /> COMMENTS <br /> f <br /> PHAU It GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY/ 'U. DATE 0 26 INSPECTION BY DATE <br /> E H 1426 Rev., 1-74�� <br /> _. h/75 2Ni _. <br />