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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. HazeltoiQ�Avp,,, Stockton, Calif. <br />{ Telephone . ('209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 9 137,3 <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />` I (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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I/f �T01#I�1�50e <br /> CENSUS TRACT <br /> Owner's' Name ��/� ;� 11'J/}/�/�� _ Ph33.E <br /> Address 7i� .!• .: _; Cit k L <br /> ,�� y <br /> Contractor's Name /gyp g2 A A/6K. License Phone.�7� p J <br /> r <br /> i <br /> TYPE OF WORK (Check),: NEW WELL/DEEPEN /% RECONDITION /—/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_Tg <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /Q/J SEWER LINES f� PIT PRIVY y <br /> p , - ; ._ �—SEWAGE_D.ISP.O,SAL-FIELD__.,,.,CESSPOOL/S �GE PI� OTHER$ C <br /> PROPERTY LINE`° -- PRIVATE DOMESTIC WEL PUBLIC DOMESTIC WELL <br /> INTENDED USE7 TYPE OF WELL s CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation3 KIWI <br /> 5 <br /> Domestic/private F Drilled Dia, of Well Ca61 --:__ <br /> Domestic/public I Driven Gauge of- Ca�_ng`� C� <br /> . � b10V <br /> G I <br /> Irrigation ! Gravel Pack Depth of.,Grou-CSeal <br /> ' Cathodic Protection �� Rotary Typed Grout <br /> Disposal Other S thtr.,'Information <br /> /F E <br /> Geophysical ur(face Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,f'f. ARMS <br /> Type of, Pump � j <br /> PUMP REPLACEMENT: . Done_ <br /> PUMPREPAIR: K� State Work Done , , f <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth 2,,w--�- <br /> t:3.Describe Materia and Procedure <br /> I hereby agree to,com'ly with all -laws and reg_ulations of the San Joaquin Local Health'District <br /> and the Staze- 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 DRILLERS REPORT" of the well and notify them before <br /> � y putting thewell. in use. The above <br /> information is true to the best of,/my knowledge and belief. I WILL CALL FOR A GROUT' INSPECTION <br /> PRIOR_TO GMAX— ACEI I_'_` E �-, <br /> SIGNED <br /> TITLE <br /> ��` ` '•- 5 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE' z <br /> 0,t ''° " ' FOR DEPARTMENT USE ONLY <br /> ` ; <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY / DATE ,? INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> WT .-j7. ... <br />