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we ywtxp�, t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT TM <br /> FOE OFFIGL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'r-1y <br /> s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-v2 <br /> (Complete In Triplicate) i <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/LOCATIONW _ CENSUS TRACT 'f5- 04Y)-S,6 <br /> Own20-6 <br /> er's NameA�l Phone <br /> ,3 <br /> Address <br /> r2 City <br /> / f <br /> Contractor`s Name e/ N License #22 Phonee <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ ECONDITION / DESTRUCTION /- <br /> PUMP INSTALLATION / / P REPAIR /^ UMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES sp PIT PRIVY �-- <br /> SEWAGE DISPO AL PELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINQ PRIVATE DOMESTIC WELL"----&-/ PUBLIC DOMESTIC WELL --� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r 1 <br /> Industrial Cable Tool, Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4/ <br /> Domestic/public Driven Gauge of Casing -7 SY <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. s <br /> PUMP REPLACEMENT: , / /--State- ,Work Done N I <br /> PUMP REPAIR: . -/7:;/=-S-tate-'Work DonOe <br /> J <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 hem before putting the..well in use. The above <br /> information is true to the bestdof. k dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIQR TO ANDIq FINAL SP I <br /> SIGNED TITLE <br /> RC1i� I <br /> f . D PLOT.PLAN ON REVERSE SIDE) j <br /> PHASE I �i�! <br /> FOR DEPARTMENT USE ONLY <br /> �T t. '' <br /> APPLICATION ACCEPTED BY , .,. DATE /- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT: 'INS PECTION "+ PHA E /FIN INSPECTION p <br /> INSPECTION BY DATE INSPECTION BY DATE 2.- -� ? <br /> F' 14 I L94; _7 A 1177 - W i <br />