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SAN JOAQUIN LOCAL HEALTi DISTRICT <br /> FOFi:OFFICE USE: !1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' — Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, z?-6l�iJ ; <br /> �kISIPEiMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ` <br /> (Complete In. Triplicate) . +. <br /> Application is hereby made Co 'the Saiz 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 Safi Joaquin Local Health District. <br /> CENSUS TRACT <br />,TOB ADDRESS/LOCATION cv <br /> Owner's Name 1/1C F Phone z <br /> Address l 7City <br /> 27` !J - �`"` - - <br /> { <br /> Contractor's Name �� �`L License #A-0-7S Phone 4g �� <br /> TYPE OF WORK (Check): -NEW WELL.' DEEPEN '/? RECONDITION /_T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/? REPLACEMENT — <br /> PUMP F7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK /6D1�'��EWER LINES 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 _ y CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of.-Well Excavation �� V <br /> Domestic/private Drilled Dia. of,.We_ 11 Caain v <br /> -Domewti�/r3blie `" Ur"iven �;_ -` Gauge of Casing <br /> _ Irrigation - Gravel Pack Depth of Grout Seal r -e- <br /> Cathodic,Proteation" , Rotary Type of Grout N e- <br /> Disposal rptteer ` -,,Other Information <br /> ` <br /> GeophysicalSurface Seal Installed 'B <br /> ... ' .' •�� • - �, .. <br /> PUMP INSTALLATION: Contracior.. <br /> 1 Type .of Pu .. H.P. - <br /> PUMP: REPLACEMENT: / /. State Work Done <br /> RUMP:REPAIR-: - /�/A State--.Work-Done _ <br /> DESTRUCTION OF WELL: Well Diameter "Approximate Depth <br /> Describe Material and Procedure tt <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 /> inFormatio s true to the•best•of my_ wledge and belief. I WILL. CALL ;FOR A GROUT INSPECTION <br /> P$IOR TO ROU IN 'AND A. FIN NSPE ON <br /> SIGNED . TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> ry FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> 't DATE , <br /> FAPPLICATION' ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: <br /> PHOS I GROUT INSPECTION PHA II ,INAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE.Z <br /> `° 4/75 2M <br /> F H 1426 RaIr. 1-74 y - <br />