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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &S F1zz <br /> 1 .a <br /> THIS PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued L-20-7,7 <br /> (Complete In Triplicate) <br /> Appli�.ation is hereby made toIthe 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 /> 11 <br /> JOB ADDRESS/LOCATION �(�;� _-� �j�'l� ,�� 1/ �.: CENSUS TRACT <br /> Owner's Name �..... r�Al/ I/I�f� /7_� �% ��!� P�i9G/F/� Phone of z <br /> Address 3 401 J:W cz,�Lc A V r__ - - City S %4gG7_1rN <br /> Contractor's Name /f 4r4License # (p2_ 'Phone 6U- 7 <br /> i <br /> x.. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION -/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE_ DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION ,SPECIFICATIONS <br /> Industrial Cable Toole Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia, of Well Casing \ 1 <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor c <br /> Type of' Pump Ys.. F _._.. . 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 Stater-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 Focal 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 UIN6 AND A FIN 1INSPECTION. F <br /> SIGNED TITLE <br /> I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAIr COMMENTS: <br /> PHASE II^GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY gn, DATE INSPECTION BY DATE <br />_ E H 1426Rev. 1-7 4 "i ' 1 f 77, M <br />