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x:, 10 i <br /> SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> FOA OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 4666781 I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 7-ZS— <br /> (Complete <br /> -7.S—(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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of t}:e San Joaquin LocaHealth District. <br /> JOB ADDRESS/LOCATION 2 /� t m1 t-f +�(�/YI� cENsus TRACT r <br /> Owner's Name ' "Ll Phone 1 STP, <br /> Address ': 9/2 ZU M , .L 4 _ City OG, prr <br /> Contractor's Name LJP�77`C�. J� �10.s _ _ _ _ License #/6a37a Phone 40(K6--1Ad_C <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN /7 RECONDITION /7 DESTRUCTION f 7 <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMP REPLACEMENT _1 <br /> Other /J <br /> s� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> y PROPERTY LINE •- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> i <br /> Domestic/private q Drilled Dia. of Well Casing <br /> E <br /> Domestic/public Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> Ai <br /> PUMP INSTALLATION: Contractor - f ��li(i1�t 42 <br /> Type of Pump gA !/ IJGt -- ---- -- H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> F.UMP�REPAiR:_ / _yState eWork,Donees <br /> ,pES TRUCTION 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 comple n o work on ne ell, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLS REPORT f thew 11 d otify them before putting the .weli in use.. The above <br /> informat on is true o e f y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G OUT G FI S CPION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ! DATE Z2- <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT4MRPECTION <br /> PHA III NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3 E H 1426 Rev. 1-74 1-74 2M -, <br />