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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave.14tockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V__/t340 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-,3-.;,7 <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 /> JOB ADDRESS/LOCATION �f_i�,�. 11'r art*zg_� 1 lee& CENSUS TRACT <br /> Owner's Name Arno I'd J. I"id�� �f�� Phone -fc����3 <br /> Address $e -140,rg ,&ry' Q,reCA., City ar, <br /> Contractor's Named License 4�.� /� Phone '-7�3� <br /> _Z 0' i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK a r f- SEWER LINES Gov r1�, PIT PRIVY <br /> SEWAGE DISPOSPELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - P NATE DOMESTIC WELL ZWftPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �U <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private *- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing id <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection z--Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:_ -ei (� <br /> PUMP INSTALLATION: Contractor A+ (3 o. �\ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 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 D S <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <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 ANDA I N. <br /> SIGNED TITLE <br /> W PLOT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 3 1 --77 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FIN NSPECTION <br /> INSPECTION BY DATE INSPECTION BY47 7 f <br /> ATE 7 <br /> E H 1426 Re . 1-74 " 1"` -711 Zr <br /> 3/76 2M <br /> v d/,- 7,11 <br />