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SAN JOAQUIN LOCALHEALTH DISTRICT <br /> ` F Wi.VFFICE USE: 1601 E. Haze Itow.Ave; ,'. Stockton,' Calif. <br /> Telephone: :...(209) 466.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-p V <br /> THIS PERMIT EXPIRES 1 YEAR ,FROM:DATE ISSUED. Date Issued /-LV-7<S� <br /> Q (Complete ,In-Triplicate) 300-13 <br /> Application is hereby made to the Sen 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 /> bounty Ordinance No. 1.8€2 and the Rules and Regulations-of-the San Joaquin Local. Health District. <br /> 337b <br /> JOB ADDRESS/LOCATION 1�1.n.� F�J. .. fZ,[, � yJr CENSUS TRACT -5-:5_5 <br /> Owner's Name �, ,, Phone <br /> Address _71-5113 . rbc.,.:. _ .�,- �. .. _..s f�. City <br /> r�. <br /> Contractor's Name _P License # f J2J�j _Phone <br /> TYPEOF WORK (Check) NEW WELL -DEEPEN' /_� RECONDITION /-7 DESTRUCTION /7 <br /> ` PUMP INSTALLATION / / PUMP REPAIR. /-7—pump REPLACEM1hff _ <br /> AE <br /> w . Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER_ LINES PIT PRIVY <br /> L/ E Y OTHER LN <br /> --- J <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBi;ICDOMESTIC 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 4f1 <br /> Domestic/public { Driven Gaugg ,o€ ,Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal � . p <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 /> r. PUMP='.REPAIRs-.--.:.. �...�.,./_.� rt-State=Woxk-Doz:e'`;-� '4 <br /> ,p l - -Approximate_Depth- _- <br /> ES:TRIJCTION=OF�WELL:` ��,,We1�.�Diametery.,.: -_-• - .� --� <br /> Describe Material and Procedure <br /> I hereby agxasto cdmply`-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 /> ! PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SIGNED 0 TITLE 4a,'-t,41 <br /> :1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> HASE I <br /> `,PLICATION ACCEPTED BY '" DATE <br /> .),ITIONAL COMMENTS: ► <br /> PHAWI I GROUT INSPECT ON P S / AL INSPECTION <br /> ?CYTON. BY `t DATE INSPECT DATES- ,S <br /> ._. �. . . <br /> 3426 Rev.+ 1-74 1-74.,21��E_ <br />