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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Top- OFFI,C9, US.E. 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> - <br /> Telephone: (209) 466-6781 v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7d '�� f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ly2e <br /> (Complete In Triplicate) <br /> Application is Aereby 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 /> r <br /> JOB ADDRESS/LOCATION ./(," CENSUS TRACT <br /> Owner's Name C1/�.y.c/£ � �Cnni Phone '-M- ftil2 F <br /> Address ��4 �"n1�- - - �' . /� ,.o.,.v 6C c✓. City <br /> Contractor's Named 4z6e& 4L24,1Z a//"", e License Phone.. � <br /> i <br /> TYPE -OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION/7 7- DESTRUCTION--/7�--= - w <br /> PUMP INSTALLATION / / 'PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK,�6 �� SEWER LINES ,�f PIT PRIVY <br /> SEWAGE. DISPOSAL� IELD CESSPOOL/SEEPAGE PIT OTHER <br /> - PROPERTY: LINL/b iRIVATE DOMESTIC WELL621�/' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation /A 't <br /> Domestic/private Drilled ` � Dia. of Well Casing /X- <br /> ,Domestic/public f Driven Gauge of Casing _ 0!4 lrwcr/l <br /> Irrigation Gravel Pack Depth of Grout Seal �J — } <br /> Cathodic Protection Rotary Type of Grout <br />— Disposal Other Other Information,("Fr.r LA122 <br />—Geophysica3� Surface Seal Installed By: - Y e,' <br /> PUMP INSTALLATION: Contractor } <br /> Type: of--Pump--- :—L�- H.P. i <br /> PUMP REPLACEMENT:, .,s r >/ State Work Done - - -- - -- -- -�� <br /> PUMP .REPAIR: _ / / State Work Done _ <br /> DES•TRUCT.ION OF WELL: Well Diameter Approximate Depth <br /> y � - <br /> Describe Material and Procedure <br /> I hereby agree to comply with{iall 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 ori 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 thebest .0 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING D A FAA N <br /> SIGNED TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE /FIN INSPECTION <br />' INSPECTION BY DATE INSPECTION B DATE S <br /> �_ E.�H 1426 Rev. 1-74 1/77�2M <br />