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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. -,��8lrJ <br /> 77- y p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-7- Z7 <br /> p (Complete In Triplicate) <br /> tIApplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> t 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 2- Q CENSUS TRACT <br /> Owner's Name / b [�E T 1lt�E �'�L Phone <br /> ' City <br /> Address S <br /> License #� 0L7 q Phone <br /> Contractor's Name iLI01 C ��/ � .,171 G . - J =� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN "/ / ` RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION _K/ REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other / / <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANK nn SEWER LINES /,0j2, . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPtiTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j Industrial Cable Tool Dia, of Well Excavation ZIEC <br /> , Domestic/private Drilled., Dia, of Well Casing 2 /` <br /> Domestic/public Driven Gauge of Casing r�/df�• — -�� <br /> Irrigation <br /> Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout 9 TF <br /> Disposal Other Other Information <br /> Geophysical 5 f Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor G G <br /> T YP. of- Pump S'�1 2`"iE'��.�� H.P. <br /> Type <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:REPAYR-:— <br /> State-Work-Done "Y <br /> DE5-TRUCTION OF WELL: Well Diameter' Approximat6- Depth <br /> Describe Material and Procedure <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 <br /> WDLL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> t information is true to thebest of my knowledge and.belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AN4 A F AL IN-SP--EON. <br /> SIGNED TITLE <br /> F ' <br /> DRAW PL°T PLAN 'ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY '] <br /> PHASE I DATE q-17 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> • PHA I GR UT INSPECTI N DATE <br /> ' INSPECTION BY ? AAT INSPECTION BY <br /> wel Itk/eek/-' 3/76 214 <br /> E H 1426 Rev. 1-74 <br />