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su 6 SAN X OAQUIN LOCAL HEALTH. DISTRICT Aye- <br /> ,4 <br /> FOR;8iFFICE US.E: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> __�z Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ti- mss! yC <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued <br /> Dtd.� ,tin -� iso -Barr/ the</ ;:(Complete In Triplicate) <br /> Application is hereby made totthe 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/LOCATIONCENSUS TRACT <br /> Owner's Name ;S' Phone <br /> Address S 4GZ/ f =`T City <br /> Contractor's Name _ i License Lyj '��-.Phone 44 -)r-,- 74;7 ; <br /> T <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN RECONDITION /-7 DESTRUCTION j7 <br /> PUMP INSTALLATION/X PUMP REPAIR %/ PUMP REPLACEMENT /7 <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TAIJK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE- OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial it Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia...,ot,:Well_Casing ; <br /> Domestic/public . -# - Driven Gauge of,,,Casing -'" <br /> Irrigation~ Grave..Pack�-..._-=Depth-of4Grout--Seal <br /> Type <br /> f Grout <br /> DisCatpodic osal Protections- Othery OtheroInformation ' <br /> P <br /> Geophysical �r i E Surface Seal Installed By: <br /> YPUMP INSTALLATION: Contractor <br /> Type of Pump e . . H.P. <br /> V <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP -Fdff!2k= //XX/ State Work Done 12-2 I01'4' <br /> DESTRUCTION OF"WELL: Well Diameter Approximate Depth r.. <br /> Describe,Material arid -Procedure <br /> I hereby. agree to comply withaall 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 t. knowledge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN N <br /> SIGNED ITLE r� <br /> W' <br /> PLOT PLAN ON VVERSE SIDE' <br /> ' FOR DEPARTMENT -USE ONLY <br /> PHASE .I <br /> APPLICATION,-ACCEPTED BY s DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION 'PHASE ,III/FINAL INSPECTION <br /> INSPECTION BY ` DATE INSPECTION BY D TL 69 <br /> E <br /> x sir ' <br /> E H 1426` :.':' Rev. 1-74 <br />