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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. ; Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-- ,20D10 <br /> THIS PERMIT EXPIRES 1. YEAR ,FROM-DATE--ISSUED. -Date Issued <br /> (Complete In .Tripl`icate) <br /> Application is hereby made to the San Joaquin Local 'Health District fox .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. 1862nd the Rules and Regulations of: t � <br /> he•.,S -Joaquin.Local Health District.. <br /> � <br /> JOB IADDRESS/LOCATIOW- - "��_. n ��Z/ .j a: CENSUS' TRACT: - <br /> Owner's Name _ _L5:r,q_Z0.y l6dd!.7F-� .. �. Phone <br /> I <br /> Address L ...... . ___... - _ <br /> I <br /> City z_S'C,2 fir/ <br /> Contractor's Name <br /> License <,7 7 ore Phone Xf,&&o <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /_7 RECONDITION %? DESTRUCT'ION f7 <br /> PUMP INSTALLATION./ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL'FIELD CESSPOOL/SEEPAGE PIV., OTHE .4 <br /> PROPERTY LINE —PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `J <br /> I CONSTRUCTIflN •SPECIFICATIONS <br /> I Industrial Cable Tool Df&...of. Well Excavation <br /> Domestic/private DrilledDiaii:of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br />` Irrigation Gravel Pack l Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other InformationK +r.-• <br /> Geophysical Y Surface Seal. Installed B i'S . <br /> PUMP INSTALLATION: _,_,_Contractor,,-_ <br /> Type of Pump - <br /> ., H.P'. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP`REPAIR: """ _ - St8te Work`Done" �`'p[f__ .� <br /> 7 <br /> E&TRUCTION 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 furni-sh-the-San_J.oaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..we17 in.use... The above <br /> information is true to the-best-of my.knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU ING AND FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE,SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . APPLICATION ACCEPTED BY DATE ,-� � <br /> ADDITIONAL COMMENTS: . - - <br />' PHASE II GROUT INSPECTION PHASE II •INAL INSPECTION <br /> INSPECTION! BY DATE INSPECTION BY- <br /> gj.00AU DATE <br /> f E H 1426 Rev. .1-74 <br /> . 1-74 2M <br /> r <br />