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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk OFFICE <br /> USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> ► Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued y- t/-79 <br /> E (Complete In Triplicate) <br /> I Application is >�iereby 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'. l62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONS 1 Q d" l IVIG CENSUS TRACT <br /> Owner's Name L lay i SONS AIPJY Phone <br /> Address -' N city " <br /> I =_ —_=.License # Phone l JSS"t� <br /> Contractor's Name r�(')1~�111(•, �Lt m�___ �_ <br /> TYPE OF WORK (Check} ; NEW WELT, l-7 DEEPEN / / RECONDITION /? DESTRUCTION /7 <br /> PUMP !INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT I�"T <br /> Other <br /> C <br /> DISTANCE TO NEAREST: SEPTIC TANK . r­';,"SEWER-LINES `, _ PIT PRIVY ;> <br /> SEWAGE DISPOSAIIELD"` --_-""SES'SPOOL-/SEEPAGE "PIT --OTHER <br /> :-F <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> g INTENDED USE iTYPE OF WELL r=_. CONSTRUCTION SPECIFICATIONS <br /> t�t Industrial t Cable°Tool Dia, of Well Excavation <br /> f, Domestic/private Drilled ;1;, Dia. of Well Casing C <br /> K Domestic/public Driven _ Gauge of Casing . T <br /> •b:f <br /> i Irrigation �} Gravel P.a_ck'"-_ ''Depth "of"Grout,-Seal <br /> Cathodic Protection ; Rotary Type of Grout : _, <br /> — Disposal Other Other Informat_an <br /> k Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor M <br /> kType of Pump en C.. WCL .P. <br /> PUMP REPLACEMENT: /_/ ,,State Work Done <br /> o PUMP .REPAIR: / / State Work Done _ <br /> J,DES•TRUCTIONOF 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 bistrict <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 /> SWELL DRILLERS REPORT of the'.well and notify them before putting the well in use. The above <br /> . information ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G G 4AD A FINAL INSPECTION. <br /> . SIGNEDTITLE <br /> `= F - (DRAW PLOT PLAN ON REVERSE STD <br /> :' OR <br /> DEPARTMEIJT USE ONLY <br /> ': PHASE I <br /> APPLICATION ACCEPTED BY /yi-o.,.� DATE <br /> ''QDITIONAL',"COMMENTS: <br /> x 'PHASE. Il ,.GROUTrINSPECTION PHASE III/FINAL INSPECTION . <br /> 'SSPECTION BY . DATE INSPECTION BY DATE <br /> 1177 2N <br /> H 1426 Rev. 1-74 <br />