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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE-OFFICE USE: (APPLICATION <br /> 1601_ E. Hazelton Ave., ,Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> FOR WELL CONSTRUCTION OR PUMP ,PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 12--yo C-0 • e-.rw�.--57-u,..J s'cFtco� /�• (Complete In Triplicate) /3( - (7 G -o/ . <br /> Application is -fiereby 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 gulation%,f th San Joaquin Local Health District. <br /> JOB ADDRESS AOCATIO v r �Vfv V4� 72!1 &L."CENSUS TRACT <br /> Owner's NameZ7 4 ;P_5` fAJC,. Phone44fz <br /> Address _100V Cit -17 <br /> es <br /> Contractor's Name ��1� � y License 7X3773 Pho '614 <br /> _ I <br /> TYPE OF WORK (Check): NEW WELL-& DEEPEN "/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR f_1 PUMP REPLACEIONT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 SPECIFICA S ¢ <br /> Industrial Cable Tool Dia, of Well -Extavatiou <br /> Domestic/private Drilled Dia, of Well Casing C> <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation F Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ i <br /> Disposal Other Other Information ! g�} <br /> Geophysical Surface Seal Installed By: <br /> ' � -- -- ----- <br /> PUMP INSTALLATION: ContractorT� /U A4�� <br /> f Type of Pump 7 (-rte <br /> r <br />[ PUHP REPLAC EENT: / / State Work Done <br /> PUMP -,REPAIR: /-7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approxipatd. Depth - .' , <br /> Describe Maters a Procedure Jam- - <br /> =�.2- & �l 77:° Tiff <br /> `I hereby agree to comply with all laws and regulations of the San Joaquin Local Health bisirict <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 /> WELL DRILLERS:REPORT of the well and notify them before putting-the..well in use. The above <br /> informatioiikis true to the-best of" my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED cn� TITLE .,v <br /> rDRAW PLOT PLAN ON REVERSE SIDE <br /> --- -, . <br /> z r- v,� FOR DEPARTMENT USE ONLY <br /> PHASE I r ; .� E� <br /> APPLICATION ACCEPTED BY r ' DATE 3--3J <br /> ADDITIONAL COMLRNTS: f .s <br /> PHAS II 'GROUT INSPECTION P I41&INAL INSPECTION <br /> INSPECTION BY DATE Y�-/-7�- �INSPECTION ATE <br /> F u l47A ID . -1_7/. 1 1 1177 2K <br />