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CE USE: '� SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> FOF OFFI1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 . f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7/jr-77 <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 � A L1J J - CENSUS TRACT <br /> Owner's Name __MA Lcr-.2 Phone 13-1— 63 6j <br /> AddressqqZU).1 121d_ �q 6EM L. City Mmu <br /> Contractor's Name - � ALL ,_ 06 . License �� �Phone tC.- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION f-1 DESTRUCTION /- <br /> PUMP INST ATION / /, PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK (05-1 SEWER-LINES -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 16 " <br /> Domestic/private Drilled Dia. of Well Casing .. <br /> Domestic/public Driven Gauge of Casing <br /> i Irrigation Gravel Pack Depth-of Grout Seal- pr <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: U- 1- <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP .REPAIR: / / State Work Done <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 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 well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALF. FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F NAL INSPECTION. <br /> SIGNED _ TITLE ; <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY4* Of ZZ f <br /> DATE 711 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT PECTION PHASE /F AL INS13ECTIO <br /> INSPECTION BY 7 4 7 7 DATE INSPECTION BY DATE d <br /> E H 1426 Rev. 1-74 <br /> 11Z7. 2M �+ <br />