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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> YOAiOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> +1 I -JA APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued jt.,�a Z <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 /> JOB ADDRESS/LOCATION 173 d a S• Act dlt o CENSUS TRACT <br /> Owner's Name J cc_`l Gvo w ( } ur f I7h�4 Phone 19 — �d Aa <br /> Address -- -t 130 a ,T• Au r )11'-ki /'( C4 City Hn n 14PC47 <br /> Contractor's Name _ C4z_(wah-r D -if limo Ca License #321;15, Phone <br /> TYPE OF WORK (Check): NEW WELL ff DEEPEN r- RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /-7—pump REPLACEMENT f <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK XO SEWER LINES C%C7, 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 /> V <br /> Industrial Cable Tool Di-a. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing & Q a rh <br /> Irrigation ---c Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _- Rotary Type of Grout d- vk <br /> Disposal Other Other Information Yjgb bX <br /> Geophysical,,, Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ,?ESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ?RIO TO NG D A IAL INSPECTIO ,r- <br /> SIGNE TITLE C.e� <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> +PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P S GRA INSPECTION PHASFIFAIgZINSPECTIO <br /> INSPECTION BY DATE INSPECTION B"' DATE <br /> 5a� %Y <br /> �_ ~E H 1426 Rev. 1-74 1-74 2M <br />