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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOL OFFICE USE: R 1601 E. Hazelton Ave. , Stockton, Calif. ,+ j <br /> - <br /> Telephone : (209) 466-6781 <br /> �X . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NO -• 6 p?� <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (0- 2-�17 7 <br /> 11 (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 and1the Rules and Regulations of the San Joaquin Local Health District. : <br /> JOB ADDRESS/LOCATION S-Z)VCE ro CENSUS TRACT I <br /> 61 tA �, <br /> Owner}s Name etA Jo C LD &7- Phone ��- ��j[ <br /> Address �'�� ^,%k romw.,._ i1 <br /> City o <br /> Contractor's Name ' License # <br /> PhoneZ'/D3 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIRI I PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SSE AGE PIT OTHER <br /> PROPERTY�LINE - PRIVATE DOMESTIC WELL;`"' V PUBLIC DOMESTIC WELL f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> Industrial Cable Tool Dia. of Well Excavation don Fr 29 <br /> Domestic/private - Drilled Dia. of Well Casing 10 i ! <br /> Domestic/public : Driven Gauge of Casing t # <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protection f Rotary Type of Grout _ �� 4A-ate_ r <br /> Disposal I Other Other Information i <br /> Geophysical Surface_ Seal Installed By: 14 0-ma.i*A <br /> 1-1 if <br /> PUMP INSTALLATION: Contractor ev- <br /> Type of ;Pump IreH.P. "ZWy <br /> PUMP REPLACEMENT / / state Work Done <br /> PUMP •.REPAIR: <br /> / / State Work Done � <br /> k <br /> I <br />)ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C 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 /> Lnformation is true to th best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AN A AL--INSPECTION, <br /> SIGNED TITLE <br /> (DRA PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?HASE I L <br />�.PPLICATION ACCEPTED B DATE -o1,1 '77 <br /> ADDITIONAL COMMENTS: <br /> .PHASE II GROUT INSPECTION PHASE I/FIN INSPECTION <br /> INSPECTION,BDATE INSPECTION BY DATE <br /> SEH 4� ._: Ratr �7[�� v: t- �z J q.,A, Z . <br />