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1 ♦ A V' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W tNel <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 work herein described. This application is-made in -compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin'Local Health District. <br /> JOB ADDRESS/LOCATION �-�c SU S &Ilyle'V CENSUS TRACT <br /> Owner's -Name fu� 14N e�s �D` % �O M_�— 'Phoney-­ <br /> V <br /> Address 9y1J1 t7/J' City <br /> Contra PE fc6- „�_, Z_661'-„od --- <br /> Contractor's Name License;, 30S1 Phone `:'Sy-z78 <br /> 7-12 79 Tor. <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/'-/ ..RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR i/ /v,,;PUMP REPLACEMENT /_7 <br /> w, Other f/77 <br /> DISTANCE TO NEAREST: SEPTIC.jTANK SEWER LINES `:.. PIT PRIVY <br /> %,SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEY`PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �r <br /> INTENDED USE TYPE OF WELL -•`CONSTRUCTION.- SPECIFICATIONS W <br /> Industrial _ Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled ,`.. Dia. of Well. Casing i <br /> Domestic/public Driven `.Gauge -of: Gas.ing <br /> Irrigation Gravel Pack” Depth of-Grout_5eal <br /> Cathodic Protection Rotary ; Type of Grout ! <br /> Disposal ( Other 'SOther Information'! <br /> Geophysical Surface Sear Iinstalled BY: <br /> PUMP INSTALLATION: Contractor �f <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR.: `:`r` i./' /;--S tate Work Done 5 0 div e <br /> DESTRUCTION OF WELL: Well Diameter _ 6 944t; �9L---- Approxi ate Depth r <br /> Describe Material and Procedure D - <br /> S'U W.C.t.� ` <br /> 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 /> 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 i <br /> informatio true to theaRCRm .. nowledge and belief. "'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING D N I N <br /> SIGNED TITLE p N.;P4e--r ok <br /> 17 "(DRAW P )T' PLAN 'ON REVERSE SIDE <br /> PQr`�le�. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B.Y DATE <br /> ADDITIONAL COMMENTS: 1 �r <br /> PRASE jj,4ROUT INSPECTION PHASE IIV/FINAIW INSPECTION <br /> INSPECTION BY DATE I SPECTION DATE -� <br /> 376 2M' <br /> E H 1426 <br /> Rev. 1-74 <br />