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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FOR OFFIC USE:' — 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued s a3?7 <br /> (Complete In Triplicate) <br /> Application is bier made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work erein deocribed—ThIA aRplicatiou is made in compliance with San Joaquin <br /> County Ordinance No. 18 2 dtihe 14 <br /> le an Re uia o of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION & /�,24 CENSUS TRACT <br /> Owner's Name Ij2,d_-1h.A ,(iiCL' l'f�cf , Phone �•� - 7 <br /> Address U,2city ' <br /> Contractor's Name A � License # 29 Phone f <br /> TYPE OF WORK (Check): NEW WELL DEEP /? RECONDITION /7 DESTRUCTION / 7 <br /> PUMP INSTALLATION PUMP REPAIR 1-7—Pum REPLACEENMT /7 <br /> Other J <br /> DISTANCE TO NEAREST: SEPTIC TANK aQ01 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD / CESSPOOL/SEEPAGE PIT 0M 4)e116 7/i?0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECI T <br /> Industrial Cable Tool Dia. of Well Excavation o (� <br /> Domestic/private — Drilled Dia. of Well Casing 14,j j1 <br /> Domestic/public _T Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> i l ' <br /> PUMP INSTALLATION: Contractor ✓ ZY12n:e <br /> Type of Pump g.P. . . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: %/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to -comply with all laws and regulations of the San Joaquin Local Health 5tstrict <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 ROUTING ANDA FANAL INSPECTION. <br /> SIGNED �, v TITLE <br /> %RAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBY DATE <br /> ADDItIONAL COMMENTS: <br /> PMR4j2I 2,R WT INSPECTION PHASE <br /> III FI AL IN&PEC IO <br /> INSPECTION BY DATE Cj 77 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 Y <br />