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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OT OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466--6 7 81 <br /> APPLICATION FOR WELL CONSTRUCT10N OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES I YEAR FROM DATEISSUED, Date IssuPd <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 /> Countv Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> IT - 7 'r-.; j13,d-,--, CENSUS TRACT <br /> j- --z <br /> 4- <br /> J 0 B ADDRESS/LOCATION r-r,Q r -aL Sb—Q <br /> E st s�-de <br /> Phone <br /> -t, s t <br /> Owner's Name S t o c-. m t <br /> Address 2 E. n City <br /> License # <br /> Or <br /> 1 Phone I <br /> Contractor's Name T 0S, J i n-L-C <br /> ff sto <br /> TYPE OF WORK (Check) k NEW WELL DEEPEN RE( ONDITION fur DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> Other I / -.? --- <br /> 11�1-0 tx W, <br /> DISTANCE TO NEAREST: SEPTIC TANK 0"T, ER L NES ------- TT PRIVY 'vJ I-,L 1 3 P 0, <br /> CESSp0OL!SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD T3 <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 >411 <br /> Domestic/private Drilled Dia. of Welt Casing —14" <br /> Domestic/public Driven Gauge of CIS!11.9 <br /> Irrigation Gravel. Pack Depth of Crc,,,,,.t Seal 01 <br /> Rotary Tvpe of crour 1-er-ent-c) sac!�, MIX <br /> Cathodic Protection -- - 1 -b-by o�-,-ner <br /> X L,�cL Other Information S1 , <br /> Disposal Other <br /> Called By: d r I <br /> 01 R7 Surface Seal Insta <br /> Geophysical <br /> -b <br /> f`<-1 Iviu " - C 1 P`L <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work 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 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 to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. b E-1 C <br /> -T-1 i ,7— A, <br /> T-Tr, T (1 BY TITLE <br /> SIGNEP <br /> (DRAW PLOT PLAN ON REVERSE SIDE)_, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> 00 <br /> ADDITIONAL COMMENTS: j�)6-2�7 �j ;44A'W� <br /> �� -- <br /> — <br /> PHASE II GROUT INSPECTION P SE III/FINAL I SPECTION <br /> INSPECTION BY <br /> 7' A IN DATE <br /> INSPECTION By DATE <br /> ;:7 <br /> 1� <br /> .4- <br /> 4 <br /> 0177 ' <br /> 11 7.426 Rev. , 1-74 <br />