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Y SAN JOAQUIN LOCAL HEALTH DISTRICT �� 2 <br /> FOE OFFICE USE: 1601 E. Hazelton''iAve. , Stockton, Calif, r <br /> Telephone : II (209) 466-6783- <br /> APPLICATION <br /> 66-6781APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. r �g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X6=2 �f' <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. Tis application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 the Rules' 'and Regulations of, the ,San Joaquin Local Health District. <br /> JOB' ADDRESS/LOCATION r R CSC " CENSUTRACT�' <br /> Owner's Name � L/ iH /�' - ---- Phone <br /> Address2 :2 :.p City o N1 <br /> Contractor's Name �' <br /> License �� bf p Phone <br /> TYPE OF WORK (Check) : NEW WELL/ Ple DEEPEN % / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT -7 <br /> ,Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LINES SPIT PRIVY <br /> }r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT OTHER �� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL = PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 0 -CONSTRUCTION SPECIFICATIONS <br /> Fy dustrialCable Tool;, Dia, of Well Excavation <br /> f <br /> tic/private Drilled Dia, of Well Casing CD 5 '___ - <br /> Domestic/public ,. k Driven + Gauge of Casing Z,2_ .! <br /> Irrigation 34 \ Gravel Pack Depth of Grout Seal <br /> -=—C.athodic`Pro'tection'I A---Rotary Type of Grout <br /> _ <br /> Disposal- -- Other E Other Information <br /> Geophysical Surf Seal Installed B : , <br /> A { <br /> j PUMP INSTALLATION: <br /> Contractor r� L- 1A -C • <br /> Type of Pump H. <br /> PUMP REPLACEMENT: / / State Work Done E! <br /> PUMP -REPAIR: / / State Work Done <br /> i DESTRUCTION OF WELL, ` Well- <br /> e l-Diameter ad r: Approximate Depth <br /> Describe Material and�'Ptocedure } <br /> �r I hereby agree to comply'with`a11'-laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or4regulating well'-construction. Within FIFTEEN DAYS <br /> after completion of my'work on a new well, IF will-furiiishi the-San "Joaquin Local 'Health District a <br /> WELL RILLERS REPORT of the well and notify ,'them before putting ,th-e .well in use: The above <br /> infor on is true to t y owledge and belief, I.-WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND NAL I � E IO <br /> SIGNED - <br /> �., TITLE <br /> ! --l(DRAW 11bT PLAN 'ON REVERSt-SIDE i' <br /> FOR DEPARTMENT' USE ONLY w <br /> PHA 4 k <br /> APPLICATION ACCEPTED BY ii.__ DATE,���23-7� <br /> ADDITIONAL COMMENTS: <br /> P SE II GROUT INSPECTION IIS P / AL .INSPECTION <br /> INSPECTION BY / - DATE - 2 INSPECTION BY DATE <br /> 3/76 2M <br /> H 142.6~ -,Re-v.'-'17,74 <br />