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I 1 <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FA�.OFFIC& USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> ' Telephone: (2fl9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -,37 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f , , <br /> (Complete In Triplicate) <br /> Application is1iereby madeto 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 J9 quin <br /> County Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Local Health-Dist riet-o <br />€ JOB ADDRESS/LOCATION U902 +' NL T LN- CENSUS TRACT <br /> f <br /> Owner's Name �}_ ` � C��tiC��� Phone ' ' <br /> ' Address -a <br /> Nt� US city' °SOD i <br /> r Contractor's NameL-Domicense i; P11ax�e; Z. <br /> k i <br /> TYPE OF WORK (Check): NEW WELL /-7DEEPEN '/3 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT 0. <br /> Other s <br /> DISTANCE TO NEAREST: SEPTIC TANKC !;� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL- FIELD CESSPOOL/SEEPAGE P1T ., OTHER <br /> PROPERTY LINE ".-PRIVA.TE/DOMESTIC WELL' ._P_UBLIC DOMESTIC WELL�T 0 <br /> INTENDED USE TYPE OF WELL '-` \ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toa Dia. of Well Excavation tJ <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven *` Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal r ' <br /> I Cathodic Protection Rotary Type of Grout s <br /> Disposal Other Other Information e� <br /> Geophysical �- Surface Seal Installed;By: <br /> PUMP INSTALLATION: Contractor Goej <br /> Type of Pump - '_�� 1�1�1 _1 ') - -- - H.P. • <br /> PUMP REPLACEMENT: / / State Work Donei _ <br /> "PUMP .REPAIR: / / State' Work Done t ►.—� <br /> DESTRUCTION OF.WELL:WEL Wei1Z: ��D ame er �^-�-- .--•� ^�.'�`. "�' ' ,t. I' �.._.. '. ., <br /> —� i t �-�^- <br /> Describe Material and WPrd6edure=�t ,F,."�r"> — <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distr et <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 P T of the-well and notify them before putting the-.well in use. The above <br /> informatio a to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO R AN A FINAL INSPECTION. <br /> j SIGNED: TITLE <br /> DRAW PLOT PLAN ON REVERSE SiD � - <br /> ' ti FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t! A�:Z7, 14 <br /> DATE . <br /> 2- <br /> ADDITIONAL' COMMENTS_: o . <br /> Il GROUT INSPECTION PHASE III FINAL PEcTiow <br /> INSPECTION BY� +��,Y;.r' DATE INSPECTION BY DATE- <br /> E H 1426 '., Rev 1-74 <br /> i <br /> 1 <br />