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x t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'OFFICE USE: t 1603 E. Hazelton Ave. , Stockton, Calif. <br /> .� Telephone: , (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X33 <br /> THIS PERMIT MIRES 1 YEAR FROM DATE ISSUED Date Issued 7/_57 <br /> . 'I (Complete In Triplicate). <br /> Application ii lie y 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 a,nd the Rules .and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS./LOCATION- 22- Z/41 All RIP-49W R 12, 12-1-Pod CENSUS TRACT <br /> Owner's Name - C�,Eo �F� D -f S _ Phone . 5311 3106 <br /> Address - - S�_/-) <br /> City <br /> r t <br /> Contractor's•Name License #2QQly�Phone <br /> Y TYPE OF WORK (Check) : NEW WELL DEEPEN!J-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMPIINSTALLATION / /'. PUMP REPAIR /� PUMP REPLACEMENT .1/7 <br /> Other / / # ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT t 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/private Drilled Dia. of Well Casing ,/2 <br /> Domestic/public Driven Gauge of Casing FPA. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 4 _ Rotary Type of Grout <br /> Disposal 'I Other Other Inf ormiaf ioftV. <br /> Ceophysicalr a`,' �� � Surface Seal Installed ;:By: <br /> r,PUMP INSTALLATION:# Contractor p�,; ►� ,e.:. s. �-- <br /> Type of Pump H.P. 3 <br /> ' } <br /> PUMP REPLACEMEN <br /> T: State Work Done t <br /> State,Work=Done :: _, <br /> ,�3ESTRtTCTION OF WELL: Well DiameterApproximate Depth <br /> —Deseriba-Material-and"Piocedure- <br /> t i <br /> Y hereby agree' to comply with all lawns 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.. jThe�above <br /> information is true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROW9NG AN AFI INSP ION. <br /> SIGNED TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDErkieeea;t <br /> FOR DEPAIMTMENT_ USE <br /> PHASE I <br /> APPLICATION ACCEPTED BY _r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FI _ INSPECTI N <br /> +� INSPECTION BY I DATE INSPECTION BY DATE Ti `I � <br /> µE H,1426 ^Rev. 1-74 � ! ,a r 1-74 2H <br />