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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]Z- E42f_V <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � I <br /> JOB ADDRESS/LOCATIO.. - /?,.G,.jCENSUS TRACT <br /> Owner's Nameladen <br /> Phan <br /> R <br /> Address City <br /> za <br />. Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION / / DESTRUCTION /_7C PUMP INSTALLA'T'ION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> ,DISTANCE TO NEAREST: SEPTICITANK 7 3 SEWER LINES Z PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD '75:71- CESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I _X Cable Tool Dia. of Well Excavation S� f <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Packy Depth of ,Grout Seal <br /> Cathodic Protection Rotary Type of -Grout <br /> Disposal Other Other Information <br /> .Geophysical Surface Seal Installed-By: <br /> PUMP INSTALLATIO? : Contractor <br /> r t - Type i f Pump H.P. ' <br /> iL AP REPLACEMENT,: / / State Work Done <br /> PUbT ,.REPAIR: / / State Work Done <br /> P <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc ibe Material and Procedure <br /> 452 4K S p utl fiy-- fill t ' <br /> I hereby agree to comply with all laws an -re­euldti_onst 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 totAe best of m wledge and belief. I WILL CALL. FOR A GROUT INSPECTION <br /> PRIOR TO GR TING A NAL INSPEe. O . \ <br /> SIGNED r TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY- <br /> PHASE I ,(] x <br /> APPLICATION ACCEPTED BY N DATE. 7/ <br /> ADDITIONAL COMMENTS: <br /> 1 PHASE II GROUTNSPECTION .' III./ N" INSPECTIO r. <br /> I INSPECTION BY �. DATE INSPECTION ;B�f. DATE <br /> x. <br /> 6/77 _ 2M <br /> F P 1AW; 1?0., l_7G /-T61 /mel/ <br />