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- 444 SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR'OKEICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �- <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applidation 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 /> JOB ADDRESS/LOCATION - -j <br /> DDRESS/LOCATIONJ ,/y a-� , CENSUS TRACT <br /> Owner's Name Phone3 � <br /> Address City " Sc�216AI_ <br /> -= �- <br /> Contractor's Name A IVE& , „rG 1,,, e License Phone <br /> TYPE OF WORK (Check) : NEW WELL X1 DEEPEN / / RECONDITION DESTRUCTION /7 <br /> PUMP`INSTALLATION / / PUNK' REPAIR-/ / PUMP .REPLACEMENT 17 <br /> Other' <br /> i L . <br /> DISTANCE TO NEAREST: SEPTIC'TANK � SEWER LINES �-� PIT PRIVY <br /> •'. SEWAGE]DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY.._.LINEr PRIVATE DOMESTIC'WELL _ , PUBLIC_DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL LL CONSTRUCTION SPECIFICATIONS <br /> Industrial .1 CableTool Dia. of Well Excavation �T <br /> �( Domestic/private •t, Drilled- .. �._ i Dia. of Well Casing \ <br /> �T Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <A <br /> Cathodic <br /> � <br /> t Cathodic Protect_ ion Rotary Type of Grout __ �CF_An�.`r t <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:: / / '.State Work Done <br /> PUMP REPAIR: _./_ / State *- <br /> o p }G� vGjZFTj�/�t/F/� Sr Z-1 <br /> DESTRUCTIONOF WELL We11 ]]iameter - -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 /> WELL DRILLERS REPORT of the well and notif them before putting the well in use. The above <br /> ; information is true to the b� 't o my n ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIORTO U TNG ' A FIN IN E <br /> SIGNEEF TITLE <br /> f _ I (MUW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE- I <br /> APPLICATION ACCEPTED BY �Ip DATE -� 7 <br /> ADDITIONAL-COMMENTS: ' <br /> PHASEk17AROUT INSPECTION PHASE I /FIN INSPECTI0 <br /> , INSPECTION -BY- AhffjnqyDAT-E_- - � } ­!-INSPECTION-BY-- DATE 77 <br /> F U 7G7F, Do.. 1-7/60 ' <br /> -7b 0 ' , '*1'4(f-r� / '�rt lQ ^-' 1 177: 2M l� <br /> " <br />