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„ 3 � SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: f� 1601 E. Hazelton Ave. ,Ave. , Stockton, Calif. <br /> Telephone: x(209) 465-6/81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7t,.1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7G , <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,- TRACT <br /> ' �U L hone 26 YZ <br /> Owner's Name j r �,�'- <br /> Addressed? ” (::F. City <br /> Contractor's NameO IL. 7L , � License # 2 Dp/,'Phone , ? <br /> 271, <br /> TYPE OF WORK (Check) : NEW WELL /2711" DEEPEN / / RECONDITION / / DESTRUCTION /-7" <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 75 SEWER LINES PIT PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Zj" CESSPOOL/SEEPAGE PIT OTHER 3 Ar <br /> +' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing S � . <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 S% ) <br /> Geophysical ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ - -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP .REPAIR: / / State Work Dane <br /> •J A roximate Depth - <br /> DESTRUCTION OF WELL: Well Diameter PP P <br /> �V_ <br /> Describe Mate al and rocedure <br /> I hereby agree to wi' ha aws ani re I" k tori b " fi Sari°�Joa'quin h--Distr ct <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS j <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 ' 4 <br /> information is true to the best of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND, A INAL IAPF-CYION. <br /> SIGNED TITLE ` <br /> D PL PLAN ON R RSE SIDE) , 1a :. <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4! ' csG DATE -.2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSPE=IOP PHASE II. FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / / _ DATE ' <br /> GUlll4 G! f•�'� .� = 3/76 2M ' <br /> E H 1426 R v. l- 4 4S <br />