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} SAN: JOAQUIN LOCAL`.HEALTH DISTRICT <br /> LIDen <br /> FOPS(OFFICE USE: i 1603 E.':Hazel:t-of :Ave::, 'Stockton, Calif. <br /> Telephone i. z:(209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,. 6-7S�A) i <br /> THIS PERMIT.:EXPIRES 1,YEAR,, FROM DATE ISSUED Date' Issued <br /> :- --. _ �.• ((Complete' In,.Triplicate) <br /> Application is herebymadeto the San.,Joaquinijocalw:Flealth District for a permit to construct <br /> And/or install..the .work herein.des+cribed.,,.�-,,This application-is made in-compliance with San Joaquin <br /> :County-Ordinance. No.1.1862 and the Rules, .aud-. Reguiations,of the San Joaquin Local Health District. I, <br /> Y14 s iln 5, <br /> ,JOB ADDRESS/LOCATION.. �'7`. G!/ S' v jam':- pl - (AVIAL. f C'4SUS TRACT�I <br /> Owner P s Name �R�i��'y �l�/✓ Phone L �(�' <br /> city <br /> Contractor's Name.. L&�Lffiz;L 4' License #__ - J,/-Phone <br /> 14 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /? .DESTRUCTrION / ,] � <br /> Pump {INST LATION / j PUMP REPAIR r PUMPRREPLA"CEMENT ff <br /> W " ' 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'' R ELIC DOMESTIC WELL <br /> INTENDED USE ;TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j Cable Tool Dia. of Well Excavation _ <br /> 66be s tic/private w. Drilled Dia. of Well Casing <br /> Domestic/public Driven' Gauge of Casing.{- ' <br /> 1_/ Ir-cigation Gravel Pack Depth of Grout Seal ► <br /> Gathodic Protection !;i_ Rotary Type of Grout <br /> Disposal =i' Other Other-Information . <br /> Geophysical P Surface`Seal Installed By: l <br /> PUMP INSTALLATION: Contrattor f ' \ <br /> 'rt► Type of Pump £� �. H.P. ZTe 7 70- <br /> PUMP REPLACEMENT: / / State. Work Done /GG . ��//�l Jy�_, n rs-ly5 0* <br /> 46 <br /> PUMP !REPAIR: <br /> ,SES-TRUCTION 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 en. a new,.well, ,I will.furnish. the San Joaquin Local Health District a 1 <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in-user. The above <br /> information is true to the-bist of my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTINAND A FINAL INSPECTION. . TITLE ��/ �o,� - --- <br /> SIGNED r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I ! �} / <br /> APPLICATION ACCEPTED BY &4& DATE <br />(' .ADDITIONAL COMMENTS: ° <br /> PHASE II GROUT INSPECTION- PHASE. I-J .FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Ade`,_ <br /> Iz'y ~E H 11426- Rev. 1-74 1-74 2M <br />