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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zlz-_833[e/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2K-1136,P <br /> (Complete In Triplicate) 176 <br /> Application is hereby made to the Sun 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 16 `$te9 f �� CENSUS TRACT <br /> Owner's Name ,C9-'T7`7/3t-, / Phone <br /> Address ;f9_,,_0lm-4 <br /> CityS` cl �`T�➢ZJ <br /> Contractor's NameOv. 7-P License 37� Phorfo"�'� <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN 17 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR/? PUMP REPLACEMENT <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK1610 SEWE INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Z�` CESSPOOL/ EPXGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI T pNS <br /> Industrial Tool Dia. of Well. Excavation <br /> D�. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public.. Driven <br /> Gauge of Casing <br /> Irrigation ' Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary Disposal Ottery Type of Grout <br /> _____�� Other Information <br /> Geophysical Surface Seal Installed B <br /> 1 <br /> PUMP INSTALLATION: Contractor Dom` <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /� State Work Done <br /> eat✓v(/ <br /> PUMP 'REPAIR: / / State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter <br /> D cribs �tyei�aln�dProcedur .�,LL `4PProx�jrmate.T hereby agree to compl with allulations of the San Joaquin -ocal 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 my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTTNG AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I OR DEP AR MENT USE ONLY f ` <br /> APPLICATION ACCEPT Y r F/v1Al� DATE �/ 74 <br /> ADDITIONAL COMMENTS: G <br /> P II ROUT INSPE ION PHASZ I11jPNAL INSPECTID <br /> INSPECTION B DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />