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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA,OFFICE USE. 1601 E. Hazelton Ave.`, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7W- 5P/41,so <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Z-.Z-0-269 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Re ula ions of he San Joaquin Local Health District. <br /> S. fit-5 .� eck Aafr, ,� Koh �� OURL �ue.. S�i�,�,� P/lu..`Ft_4 , <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Namel�C,,,.. p g Phone <br /> Address <1 :1-. /c fe A-k kv°L City <br /> Contractor's Name /1,1. S L46 T-1 4„ Ct License # T4'&- 17- Phone meq- 3 YS(- <br /> TYPE OF WORK (Check): NEW WELL/-77 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> ca <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor k) d-S <br /> Type of Pump <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP 'REPAIR: /-7 State Work Done _ 1` <br /> ES•TRUCTION OF WELL: Well Diameter 5^ !! A <br /> pproximate Dept Z167 <br /> Describe Material and Proc%dure <br /> 47-1 (/e-( <-422:Wz t <br /> I hereby agree 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 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 INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY E ,. . ; DATE -, - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I14AFINAL,INSPECTION <br /> INSPECTION BY 4 XIA DATE INSPECTION BYE 77 <br /> s E H 1426 Rev. 1-74 1-74 2M <br />