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SAN JOAQUIN LOCAL 'ItALTH DISTRICT <br /> —To—r,' OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. F1 A <br /> Telephone : (209) 466-6781 � �� -� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEffMIT Permit No. <br /> S/74C <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -6 "/1 <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 ZZ 7 N CENSUS TRACT <br /> Owner's Name j„ Phone,sem- -3-L I-L <br /> Address A a 8-7 44S �, City �T oy <br /> Contractor's Name &)y ,S t- 4,4 b 0-0 o- License #JVS;75r Phone <br /> s <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /-T DESTRUCTION /-J <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT 1 <br /> Other A,/ In0%�t C-e jZ1 e wt- 4--a- <br /> DISTANCE <br /> -4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �Q <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information .t <br /> Geophysical Surface Seal Installed By:__ <br /> PUMP INSTALLATION: Contractor 00S 14-4rA eop <br /> - <br /> Type of Pump � H.P. a 0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP °.REPAIR: / / State Work Done <br /> f✓ lir �i7', � �+ <br /> DESTRUCTION OF WELL: Well Diameter� LD Prgxie pth <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 /> r <br /> information is true to the best of. my knowledge and belief. I WILL CALL 'TOR A GROUT INSPECTION r <br /> PRIOR TO GROUTING AND A FINALLINSPECTION. -, ' <br /> SIGNED - .--- .. - . _ '—TITLE...-?3i*o--��L "- <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / ` <br /> APPLICATION ACCEPTED BY W DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FIN NSPECTION 4 <br /> INSPECTION BY DATE INSPECTION BY ATE - <br /> F 14 IL ?A Rctr_ 1-71i -- <br />