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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> W]�rOFFICE USE: 1601- E. Hazelton Ave. , Stockton, Calif. <br /> / `3 7s- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-5--3&F7141 <br /> s i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin ; <br /> ,County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / rl1/. '/�{� r RD CENSUS TRACT <br /> Owner's Name 2 YZ_4Q Phone + <br /> c <br /> -Address City <br /> 'Contractor's Names :jZ 6_� lkme—h/�htj - License # Phone <br /> 'A <br /> -TYPE OF WORK (Check):. NEW WELL /rr- DEEPEN /_7 RECONDITION /_7 iDESTRUCTION f7 <br /> PUMP INSTALLATION 1i�gUMP REPAIR /7_PUMP REPLACEMENT /7 <br /> Other /_J <br /> DISTANCE TO NEAREST: SEPTIC TANK �,r-. SEWER LINES loo-,- 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ 10 <br /> mastic/private Drilled Dia. of Well Casing <br /> Domestic/public,. Driven Gauge-ofCasing_ ` . <br /> Irrigation - 7 7, ra4e1`Pack" Depth of-Grout Seal �- <br /> Cathodic P.-rotectionrotary ^^Type4of^Gout F, ,�1 ate_ Gil <br /> Disposal ' OtherOther Information ' <br /> Geophysical Surface Seal Installed By: _?,@i.C4r5e <br /> PUMP INSTALLATION: Contractor; _r__ <br /> Tgpe_ o£.xPump _ -� __Sua � . H.P. <br /> PUMP REPLACEMENT: / /` `State Work Done <br /> PUMP :REPAIR: 17 State Work,D"one . <br /> 29S-TTRUCTION OF WELL: Well Diameter Approximate Depth 4 <br /> Describe Material and- Procedure <br /> I hereby agree to comply with all lawsand regulations of the Sat: 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 /> informatiori is true to the•best of my knowledge and belief =`I_WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 20 TITLE . �D X44 <br /> DRAW PLOT- PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �. I <br /> APPLICATION-ACCEPTED-BY-.--126-/-,f..- DATE Q zy� � t <br /> ADDITIONAL COMMENTS: -~� �• u ' �� � '~ i <br /> `PHASE Il GROUTU INSPECTION - P SE IJUFINAL INSPECTION <br /> INSPECTION BY DATE, - .�-7 5 II " NSPECTION BY ATE lo h-74 � <br /> tt E H 1426 Rev. 1-74 1-74 2M <br />