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A • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> V <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - O <br /> SIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 91Z <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION V/5- 7 A' /'2D ,erC'01-601-1 _ CENSUS TRACT <br /> 3c Owner's Name d-Srelbr L (/�/Z(j Phone 93,F- Z11? <br /> Address 5 *1 fv cityY <br /> Contractor's Name ! ' ,• l2•'�'"� License fl�Oyl-?Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /% RECONDITION /7 DESTRUCTION-f; <br /> PUMP ?.NSTALLATION /% PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other <br /> Y? DISTANCE TO NEAREST: SEPTIC TANK SE'.JER LINE PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT _ OTHER _ <br /> 'i PROPERTY LINE - PRIVATE DO.VSTIC WELL _ PUBLIC DOMESTIC WELL <br /> Td INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a <br /> . + Domestic/private Drilled Dia. of Well Casing Q1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Gn ut, Seal _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal .Installed By: S ia.G•- y C <br /> PUMP INSTALLATION: Contractor14 <br /> Type of Pump ••+ H.P. <br /> PUMP REPLACEMENT: / / State Work Done Q <br /> PUMP .REPAIR: / / State Work Dore <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 or, 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 well in use. The above <br /> information is t'ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO C OUTIN; AND AAL INSPECTION. <br /> SIGNED TITL�Gly-�YWZ� <br /> (DRAW PLOT PLA14 ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> 1111ASE I 611 <br /> APPLICATION ACCEPTED BY DATE / L� <br /> ADDITIONAL COMMENTS: 4 _—_ <br /> PHASE II GROUT INSPECTION PHAS ./FIN INSPECTION <br /> INSPECTION BY _ DATE - T:15PG ;TION PY DATE12 -77 <br /> 8b1 61177 . 2M <br /> E 11 126 Rev. �1-74 <br />