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eiwv SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IF-IF 0 F%7 6 7F_FI CE USE: j / 1601 E. Hazelton Ave., Stockton, Calif. t <br /> (/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �s6 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-J -�6 <br /> (Complete In. Triplicate) <br /> Application is hereby made t, 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 <br /> iJoaquin Local Health District. <br /> .� , CENSUS TRAGI <br /> JOB ADDRESS/LOCATION <br /> Owner's Name :tt.�jR /M /►'��� )' i%/"1 (J/� � - Phone ' i/6&- iib 3 <br /> Address . - - 7� %')WD City <br /> Contractor'a Name G ✓��/1� 1IV%��C `� / !J/1� (3 License � � GO 2 Phone <br /> ftf <br /> TYPE OF WORK (Check): NEW WELL/ ��M1DEEPEN / RECONDITION /-7, DESTRUCTION (7 f <br /> PUMP' INSTALLATION /� PUMP REPAIR I PUMP REPLACEMENT rT <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK '.SEWER LINES PIT PRIVY <br /> SEWAGE.DISPOSAL FIELDt CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> I INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS v <br /> Industrial ;.j Cable Tool Dia. of Well Excavation ` <br /> - Domestic/private _ i Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation .j Gravel Pack- Depth of Grout Seal' <br /> Cathodic Protection I Rotary Type of Grout 117NT \ <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: >��/��S' V <br /> PUMP INSTALLATION: .-Contractor <br /> Type '6f Pump . �. H.P. <br /> 1 PUMP REPLACEMENT / / State Work Done <br /> PUMP 'REPAIR: /-7State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter ,:� Approximate Depth <br /> Descrlbe. 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 Scan Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify theta before putting-putting above <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG IN ANDA F NAI, INSPECTION. <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON+REV ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE / 76 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL SPECTION <br /> '. INSPECTION BY DATE INSPECTION BY DATE <br /> (175 2M <br /> � 4•II �/.7f. Dus 1-Ili r <br />