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l✓ V16(31 <br /> .NJbAQUIN LOCAL HEALTH DISTRIC. <br /> 0ErOFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -/�- <br /> (Complete In Triplicate) <br /> application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> :nd/or install the work herein described. This application is made in compliance with San Jonqui <br /> :ounty Ordinance No. 1862// and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATIION W CENSUS TRAGI <br /> wner's Namey{fh liFN r7GF�G5 f�1va Phone <br /> ddress <br /> /e 7- City ifiTi7/Zo� �i9 L <br /> ontractor's Name c-0-rW <br /> License nZ9d�/ Phone SZ Z- G3 <br /> YPE OF WORK (Check) : NEW WELLDEEPEN /_� RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_/ <br /> ISTANCE TO NEAREST: SEPTIC TANK/aaL LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/OV CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 6� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \" <br /> Industrial Cable Tool Die. of Well Excavation 117 <br /> Domestic/private Drilled Dia. of Well Casing ell RZ-A :57iG <br /> Domestic/public Driven Gauge of Casing /6 D l✓/aL L <br /> Irrigation Gravel Pack Depth of Grout Seal SO / , <br /> _ Cathodic Protection Rotary Type of Grout 7 \\ <br /> Disposal Other Other Information 12414d2✓}�� <br /> Geophysical Surface Seal Installed By: <br /> JIE INSTALLATION: contractor <br /> Type of Pump H.P. <br /> v-rn _26 - -7`/ 7 J <br /> IMP REPLACEMENT: / / State Work Done <br /> JMP REPAIR: / / State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth O f <br /> Describe Material and Proc dure <br /> OL P GSE L 4 M a17- BF 0/e S-Tc O Yeo P2 �G1zMiT <br /> hereby agree to comply with all laws and regulatio s of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> _ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> :LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> IOR TO GROUTING-AND A FINAL INSPECTION. <br /> GNED TITLE <br /> (DRAW LOT P ON REVERSE SID <br /> FOR DEPARTMENT USE ONLYLASE <br /> PLL I <br /> PLICATION ACCEPTED BY WDATE <br /> GCi(.� <br /> )DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / INSPECTION BY <br /> I FIN INSPECTION <br /> 8 <br /> 7SPECTION BY DATE $f-/fj-76 6 <br /> S r 8., <br /> e_e t -vr-d , A 4- 3 <br /> F A 1/.9F n.... i . �t 1. /7C 7M <br />