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SAN JOAQUIN LOCAL .HEALTii DISTRICT <br /> `OReOFFICE USE: 1601 E. Hazelton Ave. , ,,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. rS= X741 <br /> THIS PERMIT EXPIRES 1. YEAR .FROM DATE .ISSUER. ' Date. Issued --1_5--,7,S- <br /> (Complete <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a paras t Co construct <br /> and/or install the work herein described. . This.; application' is made incompliance. with 'an Joaquin <br /> County Ordinance No. 1862 and the Rules Regulations.. San 3oaquin Local Healih 'Disirict.= <br /> 24 ? s p , ,AV A-= g. <br /> ADDRESS/LOCATION / r( TzpvcN SUS',.TRACT Z,f_4--zoo-t <br /> Owner's Name pF►o e:`r • ' <br /> Address -Lf2 12-Z �� � <br /> City' <br /> Contractor's NameAle License # Phone / <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/7 RECONDITION /7 -DESTRUCTIONx/� v <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <br /> / I <br /> _j,e�_ Domestic/private Drilled Dia. of .Well Casing. . !/y n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1:��� Rotary Type .of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP -.REPAIR: /? State Work Done <br /> ES-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 GR90TING ANDA,&IbT INSPECTION. <br /> SIGNED TITLE <br /> T P ON REVERSE SIDE �. <br /> FOW DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE y=/ <br /> ADDITIONAL COMMENTS: AV <br /> PHASE II 00MV XXSPMION PHASE III FINAL INSPECTION <br /> INSPECTION BY bATE INSPECTION BY0/,y,,_� _ DATE /j!0- <br /> 4 E H 1426 Rev. 1-74 1-74 2M <br />