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j" F SAN JOAQUIN LOCAL kALTH. DISTRICT <br /> F{$rQFF'TCE USE; l/: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,.$=-50 3//, <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 /> A. � . <br />_JOB ,ADDRESS/LOCATION r ��' or Z2 41— -0 CE SUS TRACT <br /> Owner's Nautc01 <br /> f'J Di - �T�IC( 1� 1'Q Phone Z2._2 �� <br /> Address �d���/ s'Jf�� City <br /> Contractor's Name .C_ License # A Phone <br /> TYPE OF WORK (Check): NEW WELL-/-7 DEEPEN -/? RECONDITION /? DES'TRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMEXT /_7 <br /> ;other ._. <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ,,,-INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/public_.. .� Driven.. - .. _.,,:.Gauge of--Casing..- — -- <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> ` Irrigation Gravel Pack Depth of Grout Seal <br /> hodic Protection Rotary Type of Grout k , <br /> Disposal. , � other Other Information —. <br /> Geophysical Surface Seal Installed B. 'r. <br /> i V � <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> _ 1 <br /> PUMP REPLACEMENT: /j./ State Work Done <br /> PUMP :REPAIR: , State Work Done <br /> R �4 <br /> .,D.ES'TRUCTION OF WELL: WO-11 Diameter i� L Approximate Depth _ <br /> Describe Material and Procedure <br /> I hereby agree to comply,l.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's <br /> WELL DRILLERS REPORT of ithe 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 GROX,ING AND A FINAI <br /> SIGNED M TITLE Q//�71P1J fi <br /> (DRAW PLOT PLAN ON REVERSE SIDE) %' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .F '' f` DATE <br /> ADDITIONAL COMMENTS: iM ,a <br /> PHLSE II GROUT INSPECTION , _ PHASE IIJO/FINAL INSPECTION <br /> INSPECTION BY 1K DATE INSPEC7 ibN BY j DATE <br /> �I E H 31+26 � '. 1-•74 2M <br /> tau <br /> r <br /> Rev ,��=_1-7 4�� r <br />