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FOF OFFICE USE• )G� SAN JOAQUIN LOCAL HEALTH DTSTRI'CT <br /> --- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77-.x,6�� <br /> / r <br /> Complete In T �p <br /> Application is hereby made to the 5an (Joaquin Local Healtht <br /> tDistrict for a <br /> and/or install the work herein described. ion permit to construct ' <br /> County Ordinance No. 1862 acid the Rules andTRegulationstof the is SaneJoaquincompliance <br /> Healt San Joaquit <br /> E JOB ADDRESS/LOCATION h District. . <br /> G G CENSUS TRACT <br /> f Owner's Name <br /> ' Phone <br /> Address 4 JAG - -u <br /> ' city <br /> Contractor's Name 2Mv + u� w �- ---- -� <br /> �''� License # �908f3 phone <br /> Z :16 3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITI _ <br /> PUMP INSTALLATION ON /? DESTRUCTION /? <br /> ISI PUMP REPAIR /. / PUMP REPLACEMENT /-7 <br /> Other /% `°�"�tt k, � , �: <br /> DISTANCE TO NEA <br /> REST: SEPTIC TANK . SEWER LINES PIT PRIVY ~' <br /> SEWAGE DISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LIN - OTHER <br /> y. IN E PRIVATE DOMESTI 1 —._,,.. <br /> TENDED USE `-'� C WELL PUBLIC DO 1=11111 ' <br /> TYPE OF _.WELL MESTIC. ,WELL <br /> ;Industrial I Cable Tool CONSTRUCTION SPECIFICATION - <br /> ,___' Dobestic/private. Dia. of Well Excavation ff ' <br /> Domestic ,- _ _. DrilXed Dia. of Well Casing <br /> /public Driven Gauge of Casing 6 �� <br /> Irrigation ` <br /> Gravel Pack Depth of Gr -j <br /> Cathodic Protec-tion �*7 <br /> Disposal Rotary rout Seal <br /> Type of Grout - <br /> �� - �- ' <br /> ^Geophysical Other Other Information ,T "- ----- ' <br /> Surface Seal Installed B <br /> PUMPINSTALLATION: Contractor r ► <br /> Type of Pulnp <br /> H.P. <br /> PUMP REPLACEMENT: <br /> Z_/ State a-Work=-Done <br /> PUMP '.REPAIR:'^ 1 <br /> / / State Work Done <br /> : <br /> DE5•TRUCTION OF WELL: Well Diameter , ��� A.- <br /> Bescribe Material and Procedure Approximate Depth :, F �� <br /> fX f1d ° <br /> I hereby agree -to p com lII <br /> and thel.laws with all-III C.►Zfic77G "- s <br /> y . � and regulations of the San Joaquin Local Health District <br /> .State of California pertaining to or regulating well "construction. Within FIFTEEN DAX <br /> after completion of my work ,.on�a new well, I will furnish the San Joaquin-Local HealthS <br /> WELL DRILLERS REPORT of the well and notify them before putting -the well in use. Theabove <br /> a <br /> information is true to the best of my knowledge and belief. I WILL. CALL �'OR <br />'RIOR TO GROUTING AN A FIN A GROUT INSPECT INSPE ON. <br /> SIGNED ION <br /> rXON <br /> f TITLE , •. }i1` <br /> {DRAW PL PLAN ON REVERSE SIDE) - -�=--- <br />'HASE I ' t FOR "TINT USE ONLY <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT+ INTPECTiON '4 PHASE III/FINAL INSPECTION <br /> tPECTION BY -� DATE INSPECTION <br /> g BY <br /> . � DATE =77 - <br /> E H 1426 Rev.. 1-74 - , <br />