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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7l- (�31VL/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5;1-7-74 <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 and the Mules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -- <br /> o. i Lv l CENSUS TRACT <br /> Owner's Name no le 0 P L.S IF s Phone - x'97 2_ <br /> Address Q C <br /> . E 1 city Z, s <br /> Contractor's Name cdz L4 �� License # / S- ZPhone r.-I-V�9. <br /> TYPE, OF WORK (Check): NEW WELTZAILLATION <br /> DEEPEN 17 RECONDITION /-7 ' -'DESTRUCTION /� - T <br /> PUMP INS PUMP REPAIR -/? PUMP REPLACEMENT / f <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL YIELD 1^9 f CESSPOOL/SEEPAGE PIT OTHER ( � <br /> PROPERTY LINE PRIVATE DOMESTIC WELLYa'D-' PUBLIC DOMESTIC WELL -v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ f� <br /> _ Domestic/private Drilled Dia. of Well Casing 6 <br /> Domestic/public Driven Gauge of Casing J� l <br /> Irrigation Gravel Pack Depth of Grout SeaA <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> -Geophysical <br /> Surface Seal Installed B and -7// <br /> PUMP INSTALLATION: `Contractor W g7 jt:- ' <br /> Type of PumpL H.P. ,__ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `REPAIR: /7 State Work Done <br /> DESTRUCTION 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 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 /> information is true to thbest-of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A ZLAL INSP . <br /> SIGNED t TITLE - <br /> ,04919:2 <br /> if z (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ­ 76 <br /> ADDITIONAL COMMENTS: <br /> ------ <br /> PWE II G OUT INSPECTION PHA . I ]FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> E H 1425 Rev. 1-74 _ h/75 2M <br />