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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1, Telephone: (209) 466-6781 . . <br /> :iF APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> �r -� aG�. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued77,1 26 <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 Joaquir <br /> County Ordinance No. 1862 and 'the Rules and Regulations of .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �v p 1AN040 A <br /> CENSUS TRACT ,_ <br /> Owner's Noe 0 P2 64 p <br /> Phone � <br /> Address <br /> !A ff City � <br /> 1 <br /> Contractor i's.a.-Nam License � <br /> :IF - .�. - Phone Zai . ?_S <br /> E TYPE OF WO (Check): NEW WELL137 DEEPEN /? RECONDITION _f ^ <br /> DESTRUCTION /� <br /> i PUMP INST LATION / PUMP REPAIR -/ PUMP REPLACEmd /- <br /> Other <br /> DISTANCE TD NEAREST: SEPTIC TANK -PRIVY SEWER LINES �' PIT PRIVY �- <br /> / kl�i� SEWAGE 'DISPOSAL FIELD tr CESSPOOL/SEEPAGE PIT OTHER R� <br /> PROPERTY LINE = PRIVATE, DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> =I 1DE} USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS " <br /> Industria] Cable Tool ., Dia. of Well Excavation <br /> Domestic%private Drilled Dia <br /> Domestic /public Driven of Well Casing <br /> t Gauge of Casing. �� . 41ave <br /> Irri 'anona <br /> -- - Grl Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> w, - y Type of Grout t <br /> Disposal Other Other Information <br /> GeophysicalLi <br /> Surface Seal Installed B <br /> PUMP INSTALLAtION: Contractor x`76 <br /> I' Type .of Pump H.P. <br /> LAC „ <br /> PUMP REP — � <br /> . �� / / State Work Done <br /> PUMP :REPAIR,_. p <br /> State Work Done <br /> DES�TRUCTI&NI'OF WELL: Well. Diameter <br /> Approximate Depth <br /> I Describe Material and Procedure <br /> T he <br /> reby agree to comply- with all laws and regulations of the San Joaquin Local Health District <br />_An. 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 /> informationl'is true to-the-best .of-my knowledge and belief. I WILL CALL- VORA -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. t <br /> SIGNED <br /> PL TITLE <br /> L O REVERSE SID <br /> P SE i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY <br /> s,1DDITIONAL COMMENTS: DA <br /> !111PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY' DATE <br /> E K 1425 . 7 C �YY>^�'a� �rim <br /> ' <br /> -Rev. 1-74 <br />