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-- ! <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR�OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)�k 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -5`f4 lei <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueda-lS-74 <br /> ( Z�" ISwJ � (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 A S5/LOCATI / w� ,� Q &ULA 4 CENSUS TRACT / zct-lQn. Z� <br /> Owner's Name ev/_ss �.�2 v�`G ay r�A— <br /> t/Phone <br /> Address` City _ <br /> � f <br /> Contractor's Name /�L�A B D riYYto£ h tt � �� License ( Phone �/ ZDV <br /> w � I <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /-7 RECONDITION / 7 DESTRUCTION <br /> PUMP INSTALLATION /� PUMP REPAIR /_7PUMP REPLACEMENT <br /> Other /% r <br /> r f <br /> DISTANCE TO NEAREST: SEPTIC TANK V,V � SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CE5SPOOL/S�P GE PIT G70 q--OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial r Cable Tool Dia. of Well Excavation L x <br /> e /Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal &na <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump e- H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPIREPAIR: /_7 State Work Done - - <br /> ESJT UCTION 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 noti€y them before putting -the- well in use.. The above <br /> information is true to the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECT <br /> SIGNED TLE <br /> OW PLOT P ON REVERSE SIDE <br /> PHASE x FORD ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 'z — <br /> ADDITIONAL COMMENTS: ' 441 <br /> P T E IO PHAS /FtVAL INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r� <br /> t E H 1426 <br /> v. 1-74 1-74 2M <br />