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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,�Z"/3T 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. . Date Issued 9� � <br /> (Complete In Triplicate) <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 with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ �I � �Q fe/ AJf. CENSUS TRACT <br /> Owner's Name R6 //V 119 /7/V l/JAS --- - --- -- Phone �9� -- <br /> Address OV/2AI P461;� LR Alg , 57W/14 City <br /> Ly <br /> Contractor's Name License 41;gi fSc Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /-/—,DESTRUCTION /_ <br /> PUMP INSTALLATION "/ / PUMP REPAIR / /.- -PUMP REPLACEMENT /7 <br /> Other / / -- -- — 4�, <br /> DISTANCE TO NEAREST: ZS SEWER LINES <br /> 1,22 �, PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEF PRIVATE DOMESTIC- +IELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE—OF WELL �, CONSTRUCTION SPECIFICATIONS <br /> Industrial ,„.''' Gable,Too1 Dia. of Well Excavation /4 <br /> - Domestic/private Drilled Dia. of We11RCasing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S 1 �Q <br /> Cathodic Protection _ Rotary Type of Grout Aa., <br /> Disposal Other Other Information <br /> Geophysical Surface Seal .Installed By'; <br /> *� tr f r <br /> PUMP_. _I-NSTALLATION: ' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> k <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth JJ <br /> Describe Material and Procedure 1 <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 w_ell'construciion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, rl will furnish t7' 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 knowleldge -and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND IN INSPECTION. <br /> SIGNED If TITLE <br /> DRAW PL'T±PLAN ON .RE FRSE SIDE) <br /> "FOR-DEPARTMENT-USE ONLY <br /> PHASE I ' f <br /> APPLICATION ACCEPTED BY DATE- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-.III/FINAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY-- TE <br /> E H 1426 Rev,... -74 <br />