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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FW.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zryff-6- ; <br /> .l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued fo'fa�7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to conetruct <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 ,S�aann 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6� �14FL AJ �p 3r C <br /> 2ENSUS TRACT <br /> Owner's Name _ 1-T 0V S� 4&& ._ Phone So 7 <br /> aw <br /> Address 165 5-- F 5H5�LT-0 ICity <br /> Contractor's Name Q WN e k (n80VL""S - -- License # Phone '997-301 ' <br /> TYPE OF WORK (Check): NEW_WELL '/� DEEPEN. /? RECONDITION /_7 DESTRUCTION rf <br /> PUMP INSTALLA - 17 <br /> TION / PUMP REPAIR-/-7 PUMP REPLACEMENT <br /> Other / / --�\ <br /> DISTANCE TO NEAREST: SEPTIC TANK 2— SEWER .LINES -1�,O 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 a7r.. Cable Tool Dia. of Well Excavation U <br /> Do6stic/privote- Drilled Dia. of Well Casing <br /> Domestic/public '° - Driven Gauge of Casing -� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otecti_ on Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical. SurfaceSeaT7Ynn stalled B <br /> PUMP INSTALLATION-.----,.-Contractor - _ 'w D SE- C -� �-- <br /> . . , Type of Pum— f H.P. <br /> PUMP REPLACEMENT.: State Work Done e1?3 <br /> PUMP .REPAIR: f / State Work Done <br /> DESTRUCTION 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`constrton. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San J a m Local Health District a <br /> WELL DRILLERS REPORT of the well and. notify them before putting the l. 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 TQ TING ANDA INAL S E ON. <br /> SIGNEDTITLE f2wlNEr—l44 ad <br /> _ _- <br /> (DRAW PLOT PAN ON REVERSE SIDE) s <br /> FOR DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP D BY /9N DATE /D-1Z'76 <br /> 1 ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASP II INAL INSPECTION <br /> ' INSPECTION BY DATE INSPSCTION�BY DATE ZZ- <br /> e� X69 35 -. <br /> •vel ?"i 1 �+ <br /> ra a .01'7e w_--- . �e , h/7q 2M <br />