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SAN JOA IN LOCAL HEALTH DIS <br /> FOS.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 176- _v,/4,/, <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA IO aN 5 CENSUS TRACT <br /> T' <br /> Owner's Na �TA Phone <br /> Nam / <br /> r— <br /> Address - 6- 1O /O v,,f City ,_ L-YA1/JJ�`/V � <br /> Contractor's Name License # 1 0 Z Phone . <br /> 77 <br /> -7- 3 Y90P <br /> 3 <br /> TYPE OF WORK (Check): NEW WELL '/ff DEEPEN '/-7 RECONDITION /_� DESTRUCTION i <br /> PUMP INSTALLATION/ I PUMP REPAIR/7—pump REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK J SEWER LINES Z} PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL"— PUBLIC DOMESTIC WELL <br /> . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -Industrial Cable Tool Dia. of Well ExcavationO <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal` <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal .1 Other Other Information' ' r----- <br /> Geophysical Surface Seal InstalledBy: <br /> PUMP INSTALLATION: Contractor Ae 0/ C <br /> Type of Pump 5 H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP'�REPAIR: /7 State Work Done <br /> )ES-TRUCTION OF WELL: Well Diameter Approximate Depth lZD <br /> `''Des ribe Material and Procedure i✓r / <br /> 1JI,AKI hereby agree to comply with all law9 and eegulations 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 gill 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 t e t the-best of my..knowledge and belief-..,,,_.I WILL CALL FOR A ,GROUT INSPECTIO <br />! PRIOR TO UTI A FINAL INSPECTION. �' <br /> SIGNED - TITLE [7 <br /> 3 DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTIO P E I NAL INSPECTIJOW <br /> INSPECTION BYDATE 7/ ?i INSPECTION BY ATE 9511- _57 <br /> n -7 7 .4A <br /> � <br /> �)9 1' E H -1426 RA-w- 1-74 Z h � __ 2M <br />