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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F',OF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y J�44 <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 /> e_7(EJfruI <br /> d )CO-e �Iw.f <br /> JOB ADDRESS/LOCATION '? <br /> CENSUS TRACT <br /> Owner's Name C,14149 -4 La ALO Phone <br /> Address Z 9 75 Al. City \7—ocx Ta <br /> Contractor's Name a__LL V"iz&6License #.2AJr&� Phone <br /> TYPE OF WORK (Check) : NEW WELL // DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR '/ / PUMP REPLACEMENT /_ '_ <br /> Other f / <br /> DISTANCE TO NEAREST: „SEPTIC TANK SEWER LINES /bp PIT PRIVY A <br /> SEWAGE DISPOSAL FIELD f� CESSPOOL/SEEPAGE PIT OTHER <br /> _ <br /> PROPERTY LINE/'=rPRIVATE DOMESTIC WELL 90- PUBLIC DOMESTIC WELL ~` <br /> INTENDED USE �,r TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation/9 ,�(,< <br /> Domestic/private Drilled Dia, of Well Casing _6 <br /> Domestic/public . Driven Gauge of Casing %$'s / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X-;70' Rotary Type of Grout G� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By;,_W,, 1/ee <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: / / State 'Work Done <br /> MT .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �f Approximate Depth �d <br /> Descr'be Material and Proc ure <br /> Qa 1.1)e nt9Gl J T �/lo 7asr ,G A-,8,� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health 15istrict. <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 t best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO T GINSPECTION. <br /> SIGNEDke <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTIO PHASE III/FINAL INSPECT ON <br /> PECTION BY DATE / INSPECTION BY DATE <br /> X426 Rev. 1-74 ' 1177 2M <br />