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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOR OFFICE USE: 7 +j 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)'466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _13(-y <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Oe17 " <br /> y � i <br /> (Complete In Triplicate) <br /> ! Applicagion is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ot'WYnstall the work herein described. This application is made in compliance with San Joaquin <br /> Cobnty Ordinance No. 1862 and the Ru i and gulatin�of the San Joaquin Local Health District. <br /> 10 <br /> JOB ADDRESS/LOCATION 9-CV CENSUS TRACT <br /> IF ���"pp �� -y- <br /> Owner's Name Il zILA/L(7t< w Phone D�9�d� <br /> Address 1� - ...i city <br /> jContractor's ;Name S'p� License U '' one <br /> �f I <br /> TYPE OF WORK i"(Check): NEW WELL/ / DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> I PUMP INSTALLATION _/V PUMP REPAIR/ / PUMP REPLACEMENT /7 " <br /> Other! / / <br /> DISTANCE TO NEAREST: SEPTIC- TANK SEWER LINES PIT PRIVY <br /> f♦ SEWAGE, DISPOSAL FIELD CESSPOOL/SEEPAGE`PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMPSTIC WELL .— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL "V tii CONSTRUCTION SPECIFICATIONS �. <br /> I Industrial Cable Tool'6.;V'#)1 Dia. of Well Exca�aticn <br /> Domestic/private Drilled Dia, of Well Casing <br /> f Domestic/public Driven Gauge of Casing :i <br /> E Irrigation Gravel +,ack Depth of Grout Seal <br /> Cathodic Protection Rotary 1 (�ype of Groin ("IDisposal. Other 1� 'Other Information : <br /> i Geophysical ! SuYface SeallInstAlled By: <br /> ff l! I <br /> PUMP INSTALLATION: Contractor <br /> j Type of Pump / H.P. y <br /> I ' <br /> PUMP REPLACEMENT: / / State Work Donej6 , <br /> ti <br /> PUMP .REPAIR: 1-7 . State Work Done 1 / . <br /> +mow" on � PeXe " ' <br /> DESTRUCTION OF WELL. Well Diameter f `i`S- Approximate Depth <br /> Describe Material and Procedure) l <br /> I hereby agree to comply with,all laws and regulation'Mf� the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating';welA construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnisli^the San Joaquin Local Health District a <br /> WELL DRILLERSREPORTof the well and notify them before puiltitng the_well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTFG AND A I P ION. <br /> RSIGNED -_,�A-AZ_ �.�, TITLE <br /> .-..(DRAW...PLOT_PLAN-ON-REV£RS E_5_IDE <br /> ij FOR DEPARTMENT USE ONLY , <br /> ; PHASE I ,, a UA <br /> APPLICATION ACCEPTED B %✓� J` ! DATE M- 1,f_-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION / PHASE II FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY WjS AT - 2Z 7 <br /> f M^ E H 1426 Ray. 1-74 lh` <br />