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F <br /> �� rj SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.OFF�SE: /1601 E. Hazelton Ave. , Stockton, Calif. s <br /> : . Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -Zk-3D4_/Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued _, S 76 i <br /> ( (Complete In. Triplicate). <br /> Application is hereby made to the San Joaquin Local health District fora 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 an4 the Rules and. Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION A-,I'ra ►r� /22 Wim. ic, et CENSUS TRACT T <br /> I Owner's Name1� C' ,., ,r� ,ZaelA.®- - -- -- -- Phone ' l <br /> Address City <br /> Contractor's Name. fi E`7t' 77DLicense # hone. -=74-7Z <br /> t _ <br /> I TYPE OF WORK (Check): NEW WELL.-/7 DEEPEN /7 RECONDITION /—T DESTRUCTION /-7 <br /> PUMP INSTALLATION / C/ PUMP REPAIR 17 PUMP REPLACEMENT /7 <br /> Other 1/ / <br /> DISTANCE TO NEAREST SEPTIC.jTANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLI.C .DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL .CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation <br />+ x . Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 4 Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' { <br /> Disposal. I Other Other Information ' d1„ <br /> R ._ U <br /> Geophysical - - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type :of Pump H.P. ' <br /> p PUMP !!N#if: State Work Done " ,., / ! ` . <br />,4 PUMP ,REFAIR: /-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 <br /> WELL DRILLERS REPORT of the-well and notify them before-putting-the..well .in.use.... .The above <br /> r information is true to the.best'o --my..knowle a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS E640 . <br /> SIGNED d TITLE *-4=f <br /> r URAW YLOT PLAN ON NVERSE SIDE <br /> A . FOR DEPARTMENT USE ONLY <br /> PHASE. I . <br /> APPLICATION ACCEPTED BY DATE ' P- <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUV INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY DATE /9 <br /> E H!1426 Rev. 1--74 - <br /> 4/75 2M <br />