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2 .. <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE SE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> 77 Telephone: (209) 466-6781 <br /> ' <br /> APPLICATION -FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L- fL7 ! <br /> (Complete In Triplicate) E <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 ES C CENSUS TRACT <br /> Owner's Name & Phone <br /> Address G - AA1 77G�q City A/TC <br /> Contractor's Name /1! G License #gQQ79y Phone - <br /> TYPE OF WORK (Check) : NEW WELL DEEPENy/f"/ •R&(}NDITION /-7 DESTRUCTION /-J !. <br /> PUMP INSTALLATION PUMP REPAIR / /N PUMP REPLACEMENT /? <br /> F Other'/ / <br /> DISTANCE• TO NEAREST: SEPTIC 'TANK SEWER LINES PIT <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, `PUBLI,C• DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4. <br /> Domestic/private Drilled Dia:` of-Well, Casng" 'r' <br /> Domestic/public Driven Gauge of Casing-- 6A <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection )_ Rotary Type of Grout' �`�' = TO TE <br /> Disposal Otherr� ;, �; Other Infoxmation- ----'y <br /> Geophysical - Surface Seal Installed By: y11/p��fC <br /> �� - <br /> PUMP INSTALLATION: Contractor <br /> E Type of Pump H.P. <br /> f PUMP REPLACEMENT: / / State .Work-Done L- Lc� �• Ti9 C }� C. Q� �Ga L... <br /> f / / State Work Done � <br /> , PUMP :REPAIR: _ /c ,� <br /> 749- 7- /ltiw <br /> - - - - _ _ Aproximate.-Depth <br /> DESTRUCTION OF XELL: Well Diameter <br />� . Describe Material and Proce <br /> r' - <br /> lure - <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 DAIS <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 G ANDA WNAL. INSP CTION. <br /> SIGNED TITLE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 4 <br /> APPLICATION ACCEPTED BY9 DATE <br /> E ADDITIONAL COMMENTS: OL eyd I-R-- <br /> PHASE,11 GROUT INSPECTION PHASE VXA*ffNAIf INSPECTION <br /> INSPECTION BY DATE / Z INSPECTION BY ATE 3 7 7 <br />�� E H 1426 AeV: 1-74 <br />