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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / ?,P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued 1 -14,-79 <br /> (Complete In Triplicate) <br /> Application is hereby wade 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 /> 20"7 3.0 5, " <br /> JOB ADDRESS/LOCATION &ECo rne�- � ENSUS TRACT v <br /> Owner's Name Phone PA 2 - 14 UR <br /> AddressXU Q --. City <br /> Cbntrac or's Name Gati-t IL License #2,�, 3Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 2 DEEPEN / / RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <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 i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . - _ <br /> Irrigation Gravel Pack Depth of Grout Seal50' — V <br /> Cathodic Protection Rotary Type of Grout -hen-tnn 1:E <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump G ^-� -- H.P. 64 PL4@ <br /> -- <br /> PUMP REPLACEMENT: / / State Work Done <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 D LLERS REPORT of the well and notify them before putting the well in use. The above <br /> informat n is true to tON <br /> es knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING AND A SP CT N. <br /> TITLE <br /> SIGNED �_ -(V� <br /> ANA <br /> W r PLIOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED By DATE l Z �es-?7 <br /> ADDITIONAL COMMENTS: <br /> P I G OUT, INSPECTI N PHASE1 FIN4 INSPECTION <br /> INSPECTION BY .1 ATE INSPECTION BY DATES z <br /> . � r . 3/76 2MAw { <br /> Ii E H 1426 Rev. 1-74 <br />