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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: p / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. s��c1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedV <br /> -W73 (Complete In Triplicate) roc--/,�ev-.ZZ <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/LOCATION �/��T�/� Gf} L�iJ CENSUS TRACT <br /> Phone <br /> Owner's Name /w. r' CIlly d ' <br /> E <br /> Address /Ile 11 <br /> r e s G 2-Cz <br /> . _ � S'7�• S411 City <br /> Contractor's Name ��/��t/ LGP License # Phone <br /> t� <br /> TYPE OF WORK (Check) ; NEW WELL/_7 DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP IN_STALATIONI I PUMP REPAIR REPLACEMENTK <br /> _ N S <br /> Other l 1 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia. of Well Excavation �. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection Rotary Type df Grout J <br /> Disposal Other Other Information <br /> 1 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _H.P.Type of Pump - - H.P ,I <br /> ' I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ ;2 Approximate Depth 200 <br /> escribe Material and Procedure a. -+ c <br /> t 1351 <br /> I hereby agree to m y with al laws and egulations of th4d San aquin Local Hdhlth 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- I <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information tru o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO O A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W Pi, T PLAN ON RE FRSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Aj 0 rTG <br /> ADDITIONAL COMMENTS:` <br /> PHASE II GROUT INSPECTION PHA;E I FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev.' 1-74 <br />