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• f <br /> f w , /�/�j SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> FOF:_iOFFICE USE: v" 1601 E. Hazelton Ave ,`Stockton, Calif. <br /> I Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76'6'46 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 4 � (Complete In.Triplicate) <br /> Application is hereby made to the Sats 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 /> JOB ADDRESS/LOCATION 8 7 + a Gv 1L CENSUS TRACT <br /> 5,53 <br /> 'Owner's Name Phone r 7 <br /> Address ML ZL e'K3�7 S GA 1gCdflo;d�_ City _, &i ICU <br /> Contractor's Name ��a License #,2 00 Phone <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN -17 RECONDITION /7 DESTRUCTION f-7 <br /> PUMP INSTALLATION /71 PUMP REPAIR / 7 PUMP REPLACEMENT /-7 <br /> Otheg I r�1e L_ <br /> DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES PIT PRIVY <br />` SEWAGE� DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY :LINE -- PRIVATE DOMESTIC WELT.' _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _- Cable Tool I}Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of4.Grout \` <br /> Disposal Other Other Information <br /> V <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Conticactox �/ \ ..j. -- <br /> Type`Jof 'Pump *_aje T H.P. <br /> PUMP REPLACEMENT: / / IState Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> 2ES TRUCTION 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 Californid(pettaining to, or regulat.ing,well;construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; 1 wilf.fum' ish ,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 TOG UTING AND A-)FINAL INSPECTION. <br /> SIGNED "f TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPAIWMENT USE ONLY <br /> PHASE I. <br /> APPLICATION ACCEPTE MGI/vart DATE T-01- 74 <br /> ADDITIONAL COMMENTS: _ I <br /> `PHASE II GROUT INSPECTION PHASE II AL INSPECTIO <br /> INSPECTION BY ]DATE INSPECTION BY DATE <br /> ' ^E H 1426 '. ,Rev.- Y-74 ' , 1 1-74 2M <br />