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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFF CE-USE 1601 E. Hazelton Ave. , Stockton, Calif. <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 �� <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 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 / ?cP�C� .Sc . Se! 0CENSUS TRACT <br /> Owner's Name E_ P1 Phone 01jR!- ",2 dF'F& <br /> Address 12 1 / / <br /> ca. City �s�CGle <br /> 1 <br /> Contractor's Name License � .s� Q�Phone <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 17 SEWER LINES _k Q PIT PRIVY <br /> SEWAGE DISPOSAr FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEIVIRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> �A,, Domestic/private ^� Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing b pf/ PAI C_ <br /> Irrigation -I(- Gravel Pack Depth of Grout Seal �A . <br /> Cathodic Protection _ =3;:�� Rotary Type of Grout C Aj 7- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B ct <br /> PUMP INSTALLATION: Contractor S'1c ? 7-6 <br /> Type of Pump H.P. <br /> / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> 0e_—A0 w15G c,_ --y v �' TJ9 t s pS 7-A/-/6X41 <br /> DESTRUCTION OF WELL: Well Diameter /App oZiim to Depth 7-T-/T <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 tr e to the best of my knowledge and belief. I WILL.IG4L FOR A GROUT INSPECTION <br /> PRIOR TO GRO AND/A FIN l NSPECTION. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIM— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 00, <br /> APPLICATION ACCEPTED BY DATE ZZ - ,3 <br /> ADDITIONAL COMMENTS: _ T <br /> PHAS I GRO INSPECTION PHASE I /FIN INSPECTI N <br /> INSPECTION BY DATE /�- �f' �� INSPECTION B DATE 2 <br /> •_1-74 y„ <br />