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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk�rOFFICE USE: / .1 <br /> 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S�_O 1d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L�k-73 <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.work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862.an, the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . 6-114.3 Iyet da Lahr CENSUS TRACT 21 <br /> Owner's Name r Phone 4H--VOLC <br /> - � � - -- - - <br /> � <br /> Addressnt`, City �-f DLII-�a17 <br /> Contractor's Name � � a� � License .#;?I Phone - Z <br /> TYPE OF WORK (Check): NEW WELL DEEPER /_7 RECONDITION /_7 DESTRUCTION /7 a <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other' / <br /> DISTANCE TO NEAREST: SEPTIC €TANK jj9jol SEWER LIMES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD 5-0 CESSPOOL/SEEPAGE PIT /a Q OTHER i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial 1 Cable Tool Dia. of Well Excavation <br /> r� <br /> Domestic/private :+ Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ C Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor b idLy <br /> Type 'af Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> PUMP :REPAIR: / / S'tate Work Done - <br /> ZES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />'E 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 /> l after completion of my workon 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 FOR A-GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> � r. (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED Y � '! DATE <br /> r ADDITIONAL COMMENTS: ;�.. <br /> PMSE ,jj SROUVINSPECTION PHASE II FINAL'INSPECTION <br /> INSPECTION BY DATE INSPECT{{ION BY DATE <br /> 't E H 1426 .,Rev. 1-74- <br />