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-- SAN JOAQUIN LOCAL HEALTH DISTRICT lLA { }� <br /> A` OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 0�5 4 <br /> Telephone : (209) 466-6781 �71 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue REC 28 3977' <br /> 5 <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 hereinldescribed. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION TSCif'�-CENSUS TRACT <br /> Owner's Name Ae/!� �/��/�!� - Phone j"-Z,T— Z-rg _L <br /> Address City X AI%fid <br /> Contractor's Name � License #32I 2J Zkt6ne <br /> ZU <br /> GS fi+�rlr� !! Li' <br /> Ile <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/ / RECONDITION / / DESTRUCTION /- �y! <br /> PUMP INST�TION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> *` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 SPECIFICATIOt45 <br /> Industrial able Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br />� Domestic/public <br /> 07Z**'brriven Gauge of Casing <br /> Irri.gationavel Pack Depth of Grout Seal <br /> Cathodic Protection Mary Type of Grout <br /> Disposal. Other Other Information { <br /> GeophysicalSurface Seal Installed By:_ ,�/ <br /> _ r -7 <br /> PUMP INSTALLATION: ' ,Contractor ` . A��`•'�� <br /> §.Type of }Pump' '- H.P. - <br /> PUMP REPLACEMENT: L/ State Work Done ' <br /> PUMP .REPAIR: State Work Done .` <br /> DESTRUCTION OF WELL: Well Diameter f ? 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 re11 Igulating well construction. Within FIFTEEN DAYS,----' j <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU INGIAN A FINAL. INSPECTION. j "410� C <br /> SIGNEDoULt 'n <br /> �` TITLE <br /> (DRAW*PLOT PLAN ON REVERSE SIDE) <br /> '' FOR DEPARTMENT USE ONLY . <br /> PHASE I / �J <br /> APPLICATION ACCEPTED BY DATF,/ � <br /> ADDITIONAL COMMENTS: ;I Of y <br /> .- � .. ' P II G OUT INSPECTION ,,,,,-,PHASE IT /FINAL INSPECTION <br /> INSPECT ON Y DATE 3 -��'] '_' -INSPECTION,, BY,4' DAT -� <br /> F. H Q2E� RPur_ l-7L <br />