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SAN JOAQUIN IsOCA.I�HEALTH DISTRICT <br /> FOF OFFICE USE. 1601 E. Hazelton Ave. , ,Stockton, Calif. ' <br /> Telephone: (209)• 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -3 f VW <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued 4Q- 7 <br /> (Complete In Triplicate) ` <br /> Application is Aereby 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. 1$62 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION'J )A' .�oy - /a �{I. � 1 r�bl'1-- aou"S.1G CENSUS TRACT f 9 eL-Z00-os <br /> •Osmer's Name 2.._ L2=1- __a 1a4 � <br /> Phone , -a <br /> Address Y City ? _ <br /> T.; <br /> b <br /> Contractor's Name ����p S Pt 1?0 (a T/�G License ;� 0 �3 Phone-��2�-Lb <br /> C <br /> TYPE OF WORK (Check) : NEW WELL jX DEEPEN / / RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT 17 <br /> t B, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK AlgA) SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD g)j) CESSPOOL/SEEPAGE PIT OTHER ' -- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia, of Well Excavation E rr <br /> Domestic/private Drilled Dia. of Well Casing I /bll <br /> Domestic/public Driven Gauge of Casing ► ^T <br /> j� Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information 6&h <br /> Geophysical Surface Seal Installed By:' <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump.. H.P.., <br /> PUMPuREPLACEMENT: / / State Work'Done <br /> PUMP -.REPAIR: / / State Work "Done + <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f . <br /> I hereby agree to. comply with all laws and regulations of the San Joaquin Local Health. i . . .. <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 INSPECTIQN <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . ti <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON ERSE SIDE) V �• <br /> DEP MENT USE ONLY <br /> PHASE iI \ <br /> APPLICATION ACCEPTED BY DATE ! <br /> ADDITIONAL COMMENTS: ' <br /> PHASE I GROUT INSPECTION PHASE F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> H 1426 Rau. 1-74 �i��.._r� Ole 8/i7107 7 <br />