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l� V/ <br /> SAN JOAQUIN TACAL HEALTH DISTRICT } <br /> F06 OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z -3z/P <br /> THIS PERMIT EXPIRES 1 YEAR FRdh DATE ISSUED Date Issued X76 <br /> (Complete In Triplicate) <br /> Application is hereby made to tho San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This applieat on is made in compliance with Save Joequ"18 <br /> County Ordinance No. 1862 and the Hulas and Regulations of the San Joaquin Local Health District. <br /> jOB ADDRESS/LOCATION /S 73a Q A ZLi sv8 TRACT <br /> Owner's Name 6. y D,6R! C.".0 n A2 now 8 38Ile <br /> Address <br /> city C"4-j <br /> Contractor's Nanay SA/41- 41�0-1) License f.27*,p Phone 7 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /-7 DESTRUCTION L7 <br /> PUMP INSTALLATION <br /> ALLATION L-1 PUMP REPAIR-,0 PUMP imAceau T <br /> Other L-7 <br /> DISTANCE TO NEA-EST: SEPTIC TANK SEWER LIM PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'.. P1JdLIC_DOl�STIC WELD <br /> INTENDED USE TYPE OF WELL %AMDXRUClIOU SP1pCItIC tQ18 \ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Wall Casing <br /> Domestic/public Driven Gauge of Casiint <br /> Irrigation Gravel Pack Depth of Grout Seal (y <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informs on <br /> Geophysical Surface Seal Installed Btt <br /> PUMP INSTALLATIONt Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L7 State Work Done <br /> PUMP :REPAIR: State Work Dona <br /> DESTRUCTION OF WELL: Well Diameter 1�`f Mp Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dist et <br /> and the State of California pertaining to or regulating Mall''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wall, I will furnish the San Joaquin Local Health District <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 FOIL A GROUT INSPECTION <br /> PRIOR TO GROUTI G ANDA XININSPECTION. <br /> SIGNED A61, TITLE <br /> DRAW PLOT PLAN ON RIVER E SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1�,�, ,.Q` DATE rX& :?L <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION P1111-11 01M <br /> INSPECTION BY DATE INSPECTION <br /> ' E H 1426 Rev. 1-74 <br /> k;. <br />