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r <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /&--7:f <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 AIM 774E-e J 6,f yu L ,,q ouIt4 �nJle e S+�ac1��1 CENSUS TRACT <br /> Owner's Name �A���v�.✓iA oo F1u. ,Q, Phone [Zoq) AIV-6iS/ <br /> Address 16So So,�� NQ�c�S�e �JQ S .� gszr]S City <br /> Contractor's Name ! vU662A-beF Cin-�SrTZvc'�`loJ al WeJjoJ License # /ZO/t S Phone <br /> TYPE OF WORK (Check) : NEW WELL/:;:7r-- DEEPEN / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / UNP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a� f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/S EPACE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL rO ' PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial /able Tool Dia. of Well Excavation z8" <br /> D-mestic/private ✓ Drilled Dia, of Well Casing j(�� :0_ <br /> Domestic/public Driven Gauge of Casing •2y> Gv.4 cC! <br /> Irrigation ,/Gravel Pack Depth of Grout Seal (�,o <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Y-J'16,Z 4,3E (./7:o„rsn2.)c.ryo„► C.o R cps, A"a j <br /> Type of Pump 2)C-Gp iJc­,L H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work 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 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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A I;INAL INSPECTION. <br /> SIGNED TITLE <br /> p.� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />`-P13.ASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT SP TIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY �DAATTE� INSPECTION BY �'� DATE <br /> 426— Rev. . 1-74 _ n/77 _ 2M <br />