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' h � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF E USE: 1601 E. Hazelton Ave.,, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6--Z-2120 <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-_-50 7y <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 Joaquin <br /> County Ordinance No, 1662 and the Rules and Regulations of <br /> the Sa Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION _-- . L c¢ �' /itt I l, <br /> Owner's <br /> Y�(sssv��e CENSUS TRACT <br /> Owner's Name �91j1e,4�l ae o n/�✓/. Phone <br /> ' Address .3 S� l �.�,.0 GCS City <br /> Contractor's NameLc> License f /-�3;7td Phcae <br /> T <br /> ' TYPE OF WORK Check); NEW WELL <br /> L 7 DEEPEN '/7 RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION jp PUMP REPAIR/-7PUMP REPLACEMENT 7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICDOMESTIC 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 °p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other. Information <br /> Geophysical Surface Seal Installed By, <br /> PUMP INSTALLATION: Contractor �re?�L" <br /> Type of Pump _ S;3 rtp!� � r ,Ea HX ,-t <br /> ' PUMP FammEEMM. State Work Done 2n1 1.4 A/&212 <br /> PUMP 1EPAIR: / / State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure l" <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 wellin use... The above <br /> information is true to the beat of my-knowledge and- belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GILOUTING AND A FINAL INS Ic //,, <br /> SIGNED r TLE I di_r <br /> ' (DRAW PL64NREV SE SIDE <br /> (FOB,/DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P INSPECpT�ION <br /> � INSPECTIO14 BY DATE INSPECTION BY DATE <br /> ' E H 1426 Rev. 1-74 6/75 2M ` <br />