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SAN JOAQUIN LOCAL HEALTH DISTRICT T ^ I" <br /> FOR OFFICE,USE: 160 , Hazelton Ave. , Stockton, Calt`*V) r� L. L�-{ 'rw <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued°E' 22 1977 <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 o 1 th San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San TocuiL th District, <br /> JOB ADDRESS/LOCATION '' p F CENSUS TRACT <br /> Dwner's Name u e Phoneg:�IkL Lz_9_,.,e <br /> Address ' Zq kzil City � �F._.. <br /> 2ontraetor's Name License &EZl/Y Phone8!z/6 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL X/T DEEPEN/_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER --- <br /> PROPERTY LINEv PRIVATE DOMESTIC WELLI_Q! PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ W <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br />-Geophysical <br /> Surface Seal Installed B <br />?UMP INSTALLATION: Contractor W h t2f r-_N I ' 6 VOt N Y� <br /> l', Type o� Pump S U % -r , F8xm 5 ! H.P. <br /> 114 <br />'UMP REPLACEMENT: / / State Work Done / <br /> PUMP /REPAIR: / State Work Done -- 0k �' / ,7 <br /> Q ft(,�, ire " ��U p �-( F?6L40 P <br /> 3ES�TRUCTION OF WELL: Well Diameter Apoximate De th <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />,TELL DRILLERS REPORT of the well and 'notify them before putting the- well in use. The above <br /> Information is true to the es of m nowledge and belief. I WILL CALL FOR A GROUT INSPEGTION <br />'RIOR TO UTING D A F L S ION <br /> iIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 3xASE z FOR DEPARTMENT USE ONLY <br /> WPLICATION ACCEPTED BY l DATE z <br /> tDDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHAS I/FIN INSPECTION - <br /> INSPECTION BY DATE /Z - Z8-7:f INSPECTION BY DATE <br /> r �� x <br /> E H. 1426 Rev. 1-74 I7� ?� ''�/ <br /> _ s. <br />