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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77,x-9941 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-91-2 7 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z nli A4 ok /9,04, _ CENSUS TRACT <br /> Owner's Name ZI X F,d 4- N�NFA_ Phone , S <br /> AddressCity <br /> Contractor's Name " aZ ZZ cense 4 � 11� Phone - S <br /> =�.ea <br /> TYPE OF WORK (Check) : fig DEEPEN RECONDITION /-7 DESTRUCTION /-'T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK2m1 SEWER LINESPIT PRIVY <br /> SEWAGE DISP SO AL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL a Mi PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation Z2 <br /> Domestic/private Drilled Dia. of Well Casing _-7TI <br /> I <br /> Domestic/public Driven Gauge of Casing /0 ,X4 Z;,4 L04zl <br /> _ Irrigation Gravel Pack Depth of Grout Seal T7T <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DE&TRUCTION OF WELL: Well Diameter Approximate Depth T! <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 's true to the be s of y k wedge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRJ2 T RO AND FINAL NS CTI <br /> SIGNED TITLE -waz . <br /> rDRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> -17 17 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PliA5 jeII/FRA% INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE � ^� r 7 <br /> 7 2M <br /> E H 1426 Rev. 1-74 <br /> ? <br />