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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> EOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (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.,- A62 and the, Rules and Regulations of the San Joaquin Local Health District. <br /> E JOB ADDRESS/LOCATION :c�1�p,3,3 f-_._ �,��(� Ago�,� _- �Q� CENSUS TRACT <br /> Owner's Name _ h IL,A 0 �y Phone <br /> Address —rm City LS- C ►4/,0p✓ <br /> Contractor's Name , License 4� 7�dJV Phone <br /> ► TYPE OF WORK__(Che.ck) : NEW WELL / / DEEPEN /�/ RECONDITION /_7 DESTRUCTION /� �. <br /> f PUMP INSTALLATION I / PUMP REPAIR /� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES PIT PRIVY <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 F r <br /> Industrial Cable Tool = -Dia. of�'W61!'Excavation <br /> Domestic/private Drilled '• _, _ Dia.._Qf_•Wel1_C.a.sing._�w_ -- <br /> f Domestic/public Driven { Gauge of Casing <br /> Irrigation Gravel-Pack # Depth of Grout Seal <br /> E Cathodic P.ro'tection Rotary Type of�Grout <br /> ► Disposal Other i Other,Information;; <br /> Geophysical Suyyrfaice Seal 'Installe 'By: <br /> PUMP INSTALLATION: Contractor r. <br /> Type of Pump IJa H.P. <br /> 4PUMP REPLACEMENT: / State Work Done V <br /> PUMP .REPAIR: / / State Work Done <br /> - E <br /> 4 <br /> ' DES-TRUCTION OF WELL: Well Diameter s 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 /> SWELL 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 CALI,,FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING -AU A FIN ..I PECTION. <br /> SIGNED t « - i. TITLE ; <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION'`ACCEPTED BX;[^��;;.: C DATE ZZZ2 /-7 <br /> ADDITIONAL COMMENTS _ar .� <br /> PHASE II PROUT INSPECTION PHASE III FINAL rINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE v`"" '79 <br /> F H 1426 Rav_ 1-76 11.77 2N <br />