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TI <br /> i�__ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFy'F"FICE USE: 1601 E. Hazelton Ave. , Stockton,-Calif <br /> Telephone : (209) 466-6781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> i1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM' DATE ISSUED Date Issued -� 1 <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 ma com•liance with San Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the a oaqu' Local Health District. <br /> JOB ADDRESS/LOCATION c-12 f70 CENSUS TRACTOV <br /> I <br /> Owner's Name AA C Phone <br /> AddressC A C city/C "f VW70A= <br /> Contractor's Name t k S 1 �., License �6 S7 Y Phone G" <br /> •� ,1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITI'6N / / DESTRU"CTION <br /> PUMP INSTALLATION / / PUMP-REPAIR / / PUMP-REPLACEMENT /, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,:?- + SEWER LINES 3 CjZ}---- PIT PRIVY;- <br /> SEWAGE--DISPOSAL FIELD - -, .CESSPOOL/SEEPAGE PIT 32 -OTHER <br /> PROPERTY LINE* PRIVATE-IIOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED US-E" TYPE OF WELL• .. 4 ", t CONSTRUCTION SPECIFICATIONS ` <br /> Industrial _.."Cible Tool � Dia.1 of Well Excavata on_' <br /> �--D'omestic/private _ - Drilled ,. , Dia. of Well Casing <br /> Domestic/,public y ." Driven Gauge of Casing <br /> Irrig ti'on�--- Gravel Pack Depth of Grout Seal Q <br /> Cathodirc'Protee tion Rotary Type of Grout <br /> .DisposaOther tit. ::: ..�.w Other-.information <br /> Geophys.tcal Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor „, jkg �.. , <br /> -- ” <br /> Type of Pump -- Ss�.....Iy.tr�.._S r H.P. <br /> PUMP REPLACEMENT <br /> State Work Dane Z��' !i 1 51 .± <br /> PUMP .REPAIR: / / State Work Done M <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure " <br /> k <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 G-ROUTIN9 AND A FINAL INSPECTION. <br /> SIGNED TITLEsrkyc.� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,.� F R DEPARTMENT USE ONLY <br /> PHASE I `� <br /> APPLICATION 'ACCEPTED BY ¢� DATE 4 <br /> ADDITIONAL COMMENTS: <br /> f PHASE II GROUT INSPECTION PHAgR II NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION 73 �. DATE k/- 11-7f <br /> s <br /> 6/77 2M <br />