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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. P <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/-?07�'71 <br /> k ' (Complete In Triplicate) <br /> Application is hereby made l o 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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z 3,S~ 0 CENSUS TRACT <br /> > Owner's Name �0E COL ATORT/' Phone 39-/803 <br /> Address <br /> Al"65- City M 74G.9 <br /> Contractor's Name &jQAb<. .94JZU O INC , ---,.,..License. #_2LW _Phone - / � <br /> H, <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP] INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / I <br /> DISTANCE TO NEAREST:' SEPTIC TANK 7L2 ' SEWER LINES �0 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private f,' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /,2_4:5.64, <br /> .` IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout E <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> r <br /> Type of Pump H.P. P <br /> PUMP REPLACEMENT: / / State„Work._Done <br /> PUMP -.REPAIR: / / . State Work-Done <br /> `' ` ' ” <br /> #. DES•TRUCTION OF WELL: We11. Diameter Approximate Depth ter. <br /> Diiscribe Material_P,4nd Procedure <br /> I hereby agree to comply withAall-laws and- regulations of the San Joaquin Local Health District <br /> , and the State of California pertaining :t'o or regulating well construction. Within FIFTEEN DAIS <br /> after completion of my work on,.a new*weil, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well' .aud notify them before. putting the well in use.. The above <br /> information is true to ttte-H'est'o'f my knowledge and belief. I WILL CALL FOR A GROUT ,'INSPECTION <br /> !' PRIOR TO GROWJNG AkjD A HNAL INS ECTION. y <br /> SIGNED ... TITLE <br /> 01 V (DRAW PLOT-PLAN 'ON..:REVERSE SIDE) <br /> PHASE.1 <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY ClN DATE 1t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FI AL INSPECTION <br /> INSPECTION BY DATE — ,... 78 INSPECTION BY DATE <br /> E H. 1426 Rev. 1-74 <br />