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i <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT r <br /> 'r FOF OFFICE USE: Iw 1601 E. Hazelton Ave. , Stocktpn, Calif. ' <br /> Telephone : (209) 7466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit. No. 22-6-,21a) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> { (Complete In Triplicate) <br /> Application is hoer 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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> A tVcR�4 <br /> JOB ADDRESS/LOCATION 1200 . CENSUS TRACT <br /> Owner's Name Phone J -- ZZ e <br /> Address 4 City <br /> Contractor's Name License Phone - <br /> _ ._. Y--�_. _ ,J:_- �_ 5�•. ,,, F.. - r. +tea. � 1 <br /> TYPE OF WORK (Check) : NEW WELL 'X' DEEPEN'/_/ RECONDITION / / DESTRUCTION /_7 <br /> F PUMP .INSTALLATION / / PUMP REPAIR/�/ PUMP REPLACEMENT /_7 <br /> - Other <br /> I` A <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> i ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _PTBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Cab-lelTobl Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing To z4_7 77 <br /> Irrigation ; Gravel Pack Depth of Grout Seal (J%/ ``J" <br /> Cathodic Protection, . 'Rotary Type of Grout',.., �-- <br /> -Disposal w r I Other Other Information <br /> Geophysical '> Surface Seal Installed By: <br /> PU9P INSTALLATION: Contractor, <br /> Type- of Pump H.P. Y\ <br /> PU; REPLACEMENT: / / State Work Done y <br /> PUMP .REPAIR: / / State Work DoneR <br />' DEkRUCTION OF WELL: Well-.Diameter i Approximate Depth <br /> 1 Describe Material and Procedure <br /> I hereby' agreeto comply with all laws and "regulations of the San Joaquin Local Health District <br /> sand"the- State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> Rafter completion of -my. work on, a new well, T will furnish the San Joaquin Local Health District a _ <br /> WELL DRILLERS'REPORT.?bf the well and notify them before putting the..well in use. The above it <br /> information_is true to the best f y o edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIQR TO AND FINAL SSP LG r <br /> SIGNED' -.,,.,, _ - e•. __._ _ ... . TITLE — - _ <br /> r <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1 k� k '< 'i1 is DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GOT 9PECTIO4 PHASE IXI/FIN4qL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY I Aj Efit <br /> E H 1426 Rev. 1-74 1fZ7 ' <br />