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A�1 L. P+44 $T 70 4 SINAI <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE 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 1 YEAR "FROM DATE ISSUED Date Issued JAN 1 Y 1978 <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 /> =:"`-Mations of the San Joaquin. Local Health District. <br /> County Ordinance No. 1862 and the Rules and R t <br /> JOB ADDRESS/LOCATION E/5 B� L iZ I� � 3 �� )4&lv1 ZCENSUS TRACT <br /> �} <br /> { 1�1. 5� C ITr�� nJ �� Phone 23q- <br /> Owner's Name M . <br /> Address City <br /> q G�� CL <br /> ' Qt3l,?j Phone "5 v yl� <br /> Contractor t s Name uk��b= License #. l 1�3G-t �-� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN -/ / RECONDITION I I DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT I I <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK L" SEWER. LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 10=0 ► 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 <br /> We11 Excavation _ <br /> _X Domestic/private " Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing L(o O L <br /> Irrigation k Gravel Pack Depth of Grout Seal 4�;-D <br /> Cathodic Protection >G Rotary Type of Grout Etj— l-� I. T <br /> Disposal other Other Information QWN <br /> Geophysical. Surface Seal Installed By : _ <br /> 1 PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <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 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 /> f information is true o the best of my knowledge and belief. I WILL CALL FOR A GROUT._.INSPECTION <br /> ' PRIOR TO G UTING A AL INSPECTION. <br /> SIGNED ZOE TITLE Q <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> .. <br /> FOR DEPARTMENT USE ONLY <br /> C PHASE I DATE 6 <br /> APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE I/FIN L INSPECTION <br /> DATE — INSPEGTION BY DATE <br /> f INSPECTION BY �jir�2 _ . //o u,, <br />