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SAN JOAQUIN LOCAL HEALTH DISTRICT SCMDI0 /1601 <br /> 9;OFFICE USE: E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;F, _L. SSS`lcJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued cF <br /> r So _ wc�o rJw c (Complete In Triplicate) �tf/- 2-60-0y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const ct <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 ealth District.. <br /> Cie// -;`/ I/ <br /> JOB ADDRESS/LOCATION e <br /> C� TRACT <br /> Owner's Name �,aJ, ('p�_-t�'i - Phone 1165-- <br /> Address <br /> 6 jAddress /41- G[/), City <br /> Contractor's Name L License # �" Phone '�2.-/L�l <br /> g2w-YA2d CA f <br /> TYPE OF WORK (Check): NEW WELL /7*�DEEPEN j7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /PUMP REPAIR /`7 PUMP REPLACEMENT _/-7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> T` PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DONESTIC WELD. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a " <br /> Domestic/private Drilled Dia, of Well Casing „A2 <br /> Domestic/public Driven Gauge of Casing 'I%jam <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection _� Rotary Type of Grout <br /> Disposal M Other Other Information cm,/) e2tOWA � �* <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: <br /> J7 State Work Done <br /> ' 4 <br /> MS•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> -�T - 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 f <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 /> PRIOR TO G OUTING AND4 FINALSPECTION. <br /> SIGNED cTITLE h&IL11a, <br /> (-DW PLOT PLAN ON RMRSE SIDE <br /> FOR DEYARTMT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 10 7 7 v <br /> ADDITIONAL COMMENTS: <br /> PHASE II- GROUVINSPECM. PHASE,ZIIAFINAL INSPEC 0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 E H 1426 Rev. 1-74 1-74 2M <br />