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C 0 Y4 14-la SAN JOAQUIN. L•OCAL HEALTH DISTRICT <br /> FQR OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> tTelephone:: (209) 466-6781 v APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> H d1AN 18 1978 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issue <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 Joaquii <br /> ' County Ordinance No. 1862 and the Rules <br /> /and <br /> ^Regulations of the/San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5.01 9 9 N Ldr�/ �y,.r `�aC CENSUS TRACT ' <br /> a <br /> ' Owner's Name rrn rtcPl� ap/y./ ,cIlk Phone <br /> ' Address q iV Da LJIIdy City 4;�ddgvp,t <br /> Contractor's Name ` License .# aizact'Fyone 5 6 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN f% RECONDITION /_7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION / / /v <br /> PUMP REPAIR ' PUMP REPLACEMENT <br /> Other <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial J Cable. Tool Dia, of Well Excavation � <br /> Domestic/private Drilled Dia, of Well Casing �( <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Q Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a . <br /> Type of PumpodeH.P..' <br /> ' PUMP REPLACEMENT: % /. State Work Done <br /> PUMP .REPAIR: / State Work Done j6do0'*a,V4 _,6� <br /> ' DES.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 any knowledg belief. I WILL CALL FOR A GROUT INSPECTION~ <br /> PRIOR TO GR T G AND 'FINAL CZ;IO . <br /> SIGNED ITLE zns _r _ <br /> D L PLAN ON SE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I / <br /> ' APPLICATION ACCEPTED BY! o/ DATE <br /> . ADDITIONAL COMMENTS: —74 <br /> PHASE II GROUT INSPECTION PWASE JUIFINA14 INSPECTION <br /> ' INSPECTION BY DATE INSPECTION B ATE - <br /> e/77 2M <br /> E H 1426 Rev. - I-74 <br /> , <br />