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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOh'OFFICE USE: O1 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y-aD 77 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 6 S [,�[yt - 3 CENSUS TRACT <br /> Owner's Name <br /> f-diLetvie - we4t 3 <br /> Phone <br /> Address aZf�6 CUA(. City , <br /> Contractor's Name 2-kC <br /> License �3Phone 2 <br /> TYPE OF WORK (Check) : NEW WELL /7. DEEPEN /7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /-7, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY w. <br /> SEWAGE DISPOSAL FIELD .fib CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENIMIY <br /> LLINTENDED USE TYPE OF WELL CONSTRUCTION S ECIVICATIQN$ tv <br /> Industrial Cable Tool Dia. of Well Excavation WO <br /> Domestic/private Drilled Dia. of Well Casing i� W <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> . Cathodic Protection ;7_ Rotary Type of Grout <br /> Disposal Other Other InformationI <br /> Geophysical Surf ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .� ! / H.P. I <br /> ski <br /> PUMP REPLACEMENT: / / State Work Done �X <br /> PUMP REPAIR: FT State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Teriaan P ced <br /> el/ <br /> I hereby agxee to comply Wlth all laws and re'ulations of th San'Joaq6in Local H&alth i�ict , <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a i <br /> WELL DRILLERS REPORT of the well and notify them before putting. the .well in use. The above i <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TINGAN NAL I ECTIO " <br /> SIGNED ZTLE <br /> DRAW PLOT PLAN ON REV SE SIDE 1 <br /> . OJC DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4:� <br /> 3 <br /> P �El6qEONT INSPECTION PHASE I /F INSPECT N <br /> INSPECTION BYDATEy / INSPECTION BY RATE " <br /> E H 1426 ev 1 14 /f - f. 7 2K <br />