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I/ SAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. <br />�- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/-�1 �4� <br /> 114 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued 1/jry-76 <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 Joaquir <br /> County Ordinance No: 1862 ared the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �e� �.r•�c� �Zt,..J-CENSUS TRACT <br /> Owner's Name �po'_ � �rZ. ' ------ — ... _ Phone <br /> Address City <br /> Contractor.'s Name _..e License Phone 6 ELY <br /> TYPErOF WORK (Check): NEW ;PIECE DEEPEN '/? RECONDITION /_7 DESTRUCTION /_I <br /> PUMPIINSTALLATION PUMP REPAIR/7 PUMP REPLACEMENT <br /> '. Other <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES 50 PIT PRIVY <br /> SEWAGE DISPOSAL- -FIELD— <br /> CESSPOOI;/ OTHER F <br /> PROPERTY LINE -- PRIVATE DOMESTIC­WEL _SEEPAGETPIT L PUBLIC DOMESTIC WELL- <br /> -K-INTENDED USETYPE OF WELL _ ' CONSTRUCTION SPECIFICATIONS <br /> _' Industrial Cable Tool Dia:hof 'Well Excavation " <br /> r Domestic/private I Drilled ia. of Well Casing C <br /> Domestic/public Driven Gauge of Casing a ` <br /> Irrigation Gravel Pack- Depth�`of Grout Seal _6Z <br /> Cathodic Protection � Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical { Surface Seal.. Installed By, 82�ss..��✓ <br /> PUMP INSTALLATION: Contractor <br /> TYpei .of Pump r H.P. <br /> PUMP REPLACEMENT: <br /> / / . State Work Done <br /> PUMP .REPAIR / ./ i .State Work Done <br /> DESTRUCTION OF WELL: Well Diameters Approximate Depth <br /> Describe Material and Procedure A <br /> I herebyagree 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 Distract <br /> WELL DRILLERS REPORT of the well and notify them before putting-the-.well. in-use.. . The above <br /> information ip,, true to the. st .of my.knowledge and belief. I WILL'CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG D A INSPECTION. <br /> SIGNED TITLE i . <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ,` <br /> i PHASE I 4 . f �/ <br /> APPLICATION ACCEPTED BY D AT El I <br /> ADDITIONAL COMMENTS: I /' <br /> PHA ROUT1 INSPECTION '` PHAS III/FINAL INSPECTION <br /> INSPECTION BY rDATE 2cj 7& INSPECTION BY � DATE 7 '�,e <br /> r <br /> r m 1L2h .,.,, 'dot._ ' i_7A -. � - <br />