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SAN JOAQUIN Z;OCAL HEALTH DISTRICT j <br /> FOt��OFFTCE USEi 16(11 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. } <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , 0-75 <br /> (Complete In Triplicate) <br /> 'I ;t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein heBRulesdandThis <br /> ulationstofn he SaneJoaquimcompliance <br /> YiealthSan <br /> District mI <br /> County Ordinance No. 1862 and t g <br /> ENSUS TRACT ©C�1-07 <br /> 30B ADDRESS/LOCATION Gtl. /�-G <br /> ,. � Phone 76 �" 3 L <br /> Owner-la': Name �G�. 4u fly l� <br /> Address A- 0- 3 G 1` / <br /> CL city *, <br /> f" <br /> License # 6 37. Phone,3� <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION`S/ PUMP REPAIR /-7 PCT[ REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEARS ST: SEPTIC TANK SEWER LINES -PIT PRIVY <br />' _ .. - .. <br /> SEWAGE DISPOSAL' FIELD'T CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia', of Well Casing <br /> k Domestic/public Driven Gauge .of_ Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection RotarOther y Type of Grout Other Information <br /> `Geophysical <br /> - .Disposal <br /> : <br /> { <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of,Pump _ H.P. / <br /> PUMP REPLACEMENT: � � State Work Done <br /> f <br /> PUMP-'REPAIR:-- --------- yJ /-State-Work Done T <br /> E&TRUCTION 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 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 GW)WINg ANDA INAL INSPECTION. <br /> SIGNED t'.. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D ARTMENT USE ONLY <br /> PRASE '.I ", j <br /> APPLICATION,ACCEPTED BY C � �' � DATE G <br /> ADDITIONAL COMMENTS: ' PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE y o-7 <br /> INSPECTION BY DATE INSPECTION BY 4 <br /> V u IL9A Rpm_ 1-.74 1-74 2M <br />