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- .. SAN JOAQUIN LOCAL HEALTH DISTRICT fG <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �,4 f r � <br /> h y ���� <br /> Tele hone: � <br /> P (209)• 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> j 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 /> E and/or install the work herein described. This application is made in compliance with San Joaquizi <br /> County Ordinance No. 1862 and thejRules and Regulations of the San Joaquin Local Health District. " <br /> I JOB ADDRESS/LOCATION ` <br /> t 1./ d, c Yf CENSUS TRACT <br /> E Owner's Name �.J, 5 <br /> r Phone <br /> Address vZ7 �, <br /> . � city /t-1,�,� t tea-- <br />. <br /> Contractor's Name <br /> _.License Qg33P e <br /> -i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMPREPLACEMENT /? 1 <br /> Other %% �{ <br /> !'7 <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES ,t�. PIT PRIVY .,�.� . <br /> SEWAGE DISPOSAL FIELD ��� ' CESSPOOL/SEF�PAGE PIT yy- OTHER E <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL �,� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECT-FICATIONS" <br /> Industrial r Cable Tool Dia, of Well Excavation Rs <br /> Domestic/private [ Drilled Dia, of Well Casing IV v <br /> Domestic/public E riven Gauge of Casing / <br /> T• rrigation "�dGravel Pack Depth of Grout Seal p <br /> Cathodic Protection Rotary Type of Grout ,u r <br /> Disposal Other �--- <br /> Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor 2 <br /> Type of Pump .u-r ~ <br /> d <br /> H.P.H <br /> PUMP REPLACEMENT: / / State work Done �� �` MI5 w, ��/i✓ L <br /> 1 <br /> PUMP :REPAIR:: r..� /7/`.,S-tate_Wor-k_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 istr ct <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 Districta <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 FOR A GROUT INSPECTION <br />°RIOR TO, GR INC AnD A KAL JNSPECTION. <br /> SIGNED TITLE <br /> Y <br /> t <br /> (DMW PLOT PLAN ON REVERSE SIDE) <br /> T5 FOR DEPART NT USE ONLY <br /> PHASE I Sr}- ' --- 7X� <br /> APPLICATION ACCEPTED l� �� � � <br /> DATE �15 <br /> ADDITIONAL COMMENTS: j <br /> PHA5f. I GRO T INSPECTION �-�,$ P SE, /FINAL 2WSPECTION <br /> INSECTION BY r <br /> 78 *14A <br /> 0 DATE - - INSPECTION BYr� Rev. 1-74 f3 .s � +"`ln�.@� /zt�✓+vy T� )�� _ �..2M !, <br />