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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR; FFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f- Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S- <br /> Le 7P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' %/ <br /> (Complete In Triplicate) <br /> Application if; hereby made to, the Snit Joaquin Local health District for a permit to construct <br /> i 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 Cf 1 Ali I& S,per, 6.4 ,� ENSUS TRACT <br /> Owner's Name C' 6y-- Ph'one"' <br /> Address = Alo` A Cit <br /> Contractor's Name <br /> License � � . . hone -� -� <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/_7 RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INSTALLATION/ / PUMP REPAIR - PUMP REPLACEMENT. /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <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 /> Domestic/private Drilled Dia. of Well Casing <br /> 'Domestic/public Driven Gauge of Casing p <br /> Irrigation ; Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other OtherInformation <br /> Geophysical Surface Seal Installed 'B� : s <br /> FF <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumg '� �,.. �.• " -• `!. <br /> H.P. 9q- .PUMP REPLACEMENT: State Work Done <br /> PTTP REPAIR: State Work Done Z 14.2 <br /> nES•TRUCTION 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 an notify them before putting. the..well. in use.... .The above • <br /> information is true to the,best of. n_. w dge and elief. I,. W1L L FpR A 'GF= INSPECTION <br /> PRIOR TO ,2NG AND A FINAL IO . <br /> SIGNE JLE . <br /> DRAW LOT 1'L ON SE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE iI INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE- 1-�/Y 7 6 <br /> E H:'1426 Rev. 1-74 ' <br /> h/75 2M <br />