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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOW 'OFFI'CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 45`74) <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE 'ISSUED Date Issued <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 works herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. '1862 and the Rules and Regulations of the Sam Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �.Z` G l�P_f �I ( - CENSUS TRACT <br /> Owner's Name ' L Phone , <br /> Address / . 2 ', 404a City , <br /> .' <br /> Contractor's Name I�Im Ae <br /> 6406, `// License Phone <br /> Gel, f <br /> TYPE OF WORK (Check): .��NEWWELL DEEPEN/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP. INSTALLATION / / PUMP REPAIR -/7 PUMP REPLACEMENT f- - <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY s <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER WC-11- #0'-+ <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 " e <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing r /� 2pn <br /> Irrigation ,� Gravel Pack , Depthof Grout Seal <br /> :_ w_-.Gathad3cPraxec:tilon- --: <br /> Rotary <br /> --of-.GroutTyp <br /> Disposal' <br /> Other Other Information sQ 7,1 ,t _ <br /> Geophysical H. Surface Seal Installed BY: <br /> PUMP INSTALLATION: I�Contractor= Am ` i * <br /> Type of Pump H.P. <br /> . #. 4e <br /> PUMP REPLACEMENT: . Ir/-I State Work Done <br /> PUMP 'REPAIR: •�/ / State Work- Done <br /> DESTRUCTION OF WELL: .jWell- Diameter .� �2 � Approximate Depth <br /> .ti Describteria and Prosed re <br /> r-Adthereby agree to comply, with a 1 laws an r ulations of a San oa in Local H h <br /> tDistr ct <br /> an7 the State of Cali-faruia- pertaining°to or regulating well ''construction.. Within FIFTEENJDAYS <br /> after completion of myj'york 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 /> # information is true`to ?the.best-of- my..knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G OUTING AND!FINAL NSPECTION. - ••« :- `. - -' -"" <br /> SIGNEDTITLE i <br /> IM. W P T PLAN ON RENERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I .a - �, M , ,: <br /> APPLICATION4 ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ _ hA <br /> '4s PHASE II GROUT N3PECTI N PHAS II INSPECTI N <br /> f T&PECTION BY DATE / INSPECTION BY &44zd DATE Y 12 W '2 <br /> 'E H 1426 Rev. 1-74 �' �° �S <br />