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SAN JOAQUIN LOCAL HEALTH DISTRICT ! f <br /> FOPw.O If �77 <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 5Z-_ )&z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 60,_7`77 <br /> I (Complete In Triplicate) <br /> Application is hereby made tolthe 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 Jo4quin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -1141 b 6 a fact CENSUS TRACT <br /> Owner's Name ' <br /> Phone <br /> Address4a t fxa city � v <br /> Contractor's Name . License Phone <br /> TYPE OF WORK (Check) : NEW WELL `/_jp DEEPEN /_/ RECONDITION DESTRUCTION <br /> PUMP INSTALLATION`. /L4--� PUMP REPAIR / / PUMP `REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER` . <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . <br /> INTEN <br /> IndustrialSE TIPS CableToolDia, of Well <br /> SPECIFICATIONS" r� <br />_� 1 Excavation 7111 <br /> Domestic/private Drilled Dia. of Well Casingw _ <br /> Domestic/public Driven \� 4. - Gauge of Casing <br /> Irrigation Gravel Pack' ' Depth of Grout Seal Q a <br /> Cathodic Protection f Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �z, �r s 44 ----- H.P. , <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <br /> r`PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL-: Well Diameter ,„... '-Approximatet.Depth yi j <br /> Describe -Material and Procedure > ' <br /> I hereby agree to comply with all laws and regulatibns of the San Joaquin Local Aealth ;bistrict <br /> and the State of California pertaing,to or regulating well 'construc•rioii.`,�Within .FIFTEEN DAYS <br /> after completion of my work on, a new wel'l;, I wilf furnish they San Joaquin Local-Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .welI in use.. The above <br /> information is true to the best of my knowledge and belief. I- WILL„CALL, FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION.- ' ' - 041 ✓ <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN_ ONkREVERSE-SIDE) i <br /> FOR DEPARTMENT,USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY ., DATE !� <br /> ADDITIONAL COMMENTS: //&Aof <br /> PHARA II ROUTSPECTI �),,. P I/ NAL INSPECTIQN <br />' INSPECTION BY DATE INSPECTION BY DATE <br /> 'L'V nr a Crh4, 7 2M <br /> E H 1426 Rev. 1-74 �� r ” / <br />