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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> h FOE OFFICEdUSE: K1601 E. Hazelton Ave. , Stockton, Calif. - <br /> -Y Telephone: (209) 466-6781 <br /> r r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ,wand./ori3i�s:ta11° he-war-k�-herei.tiAdest-r-ibede >-Th sA�applicat ori•is-�made�in4compliance*with:San-Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health .District.. <br /> JOB ADDRESS/LOCATION 367Flood Road CENSUS TRACT <br /> ch Linden...:__..._ <br /> ( Owner's Name tI; 11$2 _uan-Tsl-- Phone <br /> Address --P-.n- -Rnx 6Az ._ _ City 1A nr an <br /> Contractor's Name . , License #2bO 4 Phone <br /> TYPE OF WORK (Check).- NEW WELL /_7 DEEPEN -/—/ RECONDITION / / DESTRUCTION 17 <br /> PUMP INSTALLATION '/ / PUMP REPAIR -jk / PUMP REPLACEMENT <br /> Other J / <br /> DISTANCE TO NEAREST SEPTIC�TANK SEWER LINES PIT PRIVY T <br /> = <br /> i ...�. r.;;_SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT• ' OTHER -" <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC' DOMESTIC WELL <br /> + ~--;;- ?INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Iifdus trial Cable Tool Dia. of Well, Excavation <br /> Domestic/private Drilled, -!,Dia. of Well Casing <br /> ► Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack-,,.,.,/Depth of Grout Seal <br /> j Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: . ._. <br /> PUMP INSTALLATION: Contractor Walter G jo ck :l <br /> j Type of Pump Turbine ...--- H.Pi 40 <br /> PUMP REPLACEMENT: . / / State Work,-Done <br /> — <br /> PUMP."REPAIR: State-Work-Done <br /> ` RE TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k I :hereby agr'ee to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. -Within �FISTkW tki*S. <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 FORA GROUT IP(SPECTI.04. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> M W PLAN ON RE VER SIDE) <br /> FOR-DEPARTMENT-USE'ONLY" <br /> ' <br /> PHASE I <br /> APPLICATION ACCEPTED BYBDATE Z <br /> 11/:7 <br /> ADDITIONAL OMMENxS: <br /> PHASE II GROUT INSPECTION PHAS IIF NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 7. <br /> j. <br /> 76 2 <br /> E H 1426 Rev. 1-74 <br /> 3/ .. <br />