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lSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. j <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEFXIT Permit No. ??ZZs-,0 <br /> 77_�7 3 10 <br /> THIS.PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-3-7 <br /> (Complete In Triplicate) l <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 f <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !a ae•T':��P p d �4 CENSUS TRACT J <br /> Owner's Name �' Phone "7'` <br /> Address w7'0-+v NC a roc! city S jc �Ti� •v <br /> Contractor's Name,- A2j µ tlrc License #;L 10? Phone- <br /> tl <br /> TYPE OF WORK (Check) : NEW WELL /;q; DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR "/ / PUMP REPLACEMENT <br /> Other k / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL >-75-ft CESSPOOL/SEEPAGE PIT OTHER p� <br /> PROPERTY1 LINE !� RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `y <br /> INTENDED USE TYPE OF WELL ` CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation y <br /> 4== Domestic/private Drilled Dia. of Well Casings/r <br /> Domesrtic/public Driven Gauge of Casing /2- <br /> Irrigation <br /> 2-Irrigation Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection -. t�-Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical. Surface Seal Ins--_alled By: hlVe'-5a <br /> PUMP INSTALLATION: .Contractor 6� P 0 .n ,tI 0- # 4a <br /> Type of Pump H.P. 3 . <br /> PUS REPLACEMENT: /7 S tate Work Done <br /> a <br /> PUMP .REPAIR: / / State Work Done <br /> 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Thereby 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 FIFTES <br /> EN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Lacal .Health Distiict a <br /> WELL DRILLERS�REPORT of the well and notify them before putting the",well-in use. Tpe above- <br /> information is true to the best. of my knowledge and belief. VWILLICALL.`FOR A,GROiTT IN ,ION <br />.PRIOR TO GROUTING AND A FINAL INSPECTION: a - <br />,.SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEIT <br /> FOR DEPARTMENT USE ONLr <br /> PHASE I � ,.� �` ' �`c l r .� ^''� ct <br /> APPLICATION ACCEPTED BY 1P a �-SDA E , <br />' ADDITIONAL COMMENTS f 5' <br /> P S I" ROU` SINS ECTION _ " :""PHASE INAL_:eINSPECT,, <br /> INSPECTION BY DATE" IN:SFECI�ONDATE <br /> w 3 f31. L x ' ✓�' 1 f 77 2M' ° <br />