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P <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br />-TUE-"OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 }'7D GCS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Reg--ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 17-06sy 9 <br /> 4&2A/if✓ CENSUS TRACT <br /> Owner's Name / p V' 1/4/"E Z ' /�F�' Phone 73-,'E-3-2 C/` <br /> Address r7,�5'0 til �/u.s 1'- t Af, )4/,fA17.=--,--,4 (G City <br /> Contractor's Name rk- ti! C 6011 , License Phone 44A � r <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 49 DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK : '7 SEWER LINES PIT PRIVY <br /> SEWAGE DjS;$UFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> � <br /> PROPER ,�,INE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA ONS <br /> Industrial 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 q0 _ <br /> Cathodic Protection — — Rotary Type of Grout & <br /> Qi <br /> Disposal Other Other Information S'bh hN4 OWMA r' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r --' .X. "♦, ., <br /> Type of Pump - H.P. -v <br /> PUMP REPLACEMENT: / / State Work' one <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 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 INSPECTION <br /> AL INSPECTION. <br /> SIGNED TITLE <br /> PRIOR TO G ING D <br /> W <br /> ?LOT PLAN ON RE RSE SID -- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -� DATE /Y 7 <br /> ADDITIONAL COM MEN TS: <br /> ,�o- <br /> PHASE II GROUT INSPECTION P SE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE G` <br /> vi2n <br /> E H 1426 Rev. 1-74d ' / 7 <br />