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C� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Dolr] <br /> 7�'�. 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issue( ,x"=17 <br /> �6 <br /> (Complete In Triplicate) 023- (77c-.�07 <br /> Application -ie hereby made to 'the San Joaquin Local Health District for a permit to construct <br /> and/or install the work here in;,described. This application is grade in compliance with 'San Joaquin <br /> County Ordinance No. 18_6.2 and the Rules and Regulations of the fan Joaquin Local Health District. <br /> ��.z,Z��,Q <br /> JOB ADDRESS/LOCATION c+ /, f t�/� �lI �� p f G�o�`, =Jy�1 -� CENSUS TRACT <br /> Owner's Name & U_S .7"; ��- <br /> ..,.,. Phone , 3Lg-- 5' <br /> Address 11.3 C G Z---IV HS -�- City 4-0-4 [ [ <br /> Contractor's Name ,�;��' <br /> � � ��z.G;L!Y��� G� License #�2 ea/6 Phone zi�r ©3 <br /> TYPE OF WORK (Check):"NEW WELL DEEPEN .RECONDITION f7 DESTRUCTION' j <br /> PUMP INSTALLATION PUMP REPAIR -/?PUMP REPLACEMENT % f <br /> Other j/% � ... <br /> DISTANCE TO NEAREST: SEPTIC TANK &0 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 E CONSTRUCTION SPECIFICATIONS VNj <br /> Industrial Cable Tool Dia. of Well Excavation _ „ _ to <br /> Domestic/private DAlled Dia. of Well Casing <br /> Domestic/public W, . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary z Type of Grout � � <br /> Disposal" Other Other Information ' ' <br /> Geophysical Surface Seal 'Installed B <br /> PUMP INSTALLATION: .' Contractor syl '� zt <br /> - _ .•. __�r .. -Type~of= Pomp _ __. . . - # _.�- <br /> `� __ - -__._.._ _._'.�� -•�w. .�.-.,. : .-.-x--.- -. .. H.P. <br /> PUMP REPLACEMENT`: — <br /> / / State Work Done <br /> PUMP .REPAIR: ''/=/ -State�Wark-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 anew 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY or <br /> DATE. <br /> ADDITIONAL COMMENTS:: <br /> PHASE II GROUT INSPECTION PHAS9-,ITel FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 ''`Rev. 1-74 <br /> 4/75 2M <br />