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0 Y` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> '? PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ �` <br /> (Complete In Triplicate) <br /> I <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. I <br /> JOB ADDRESS/LOCATION �i ` <br /> f �lfJV�Q CENSUS TRACT <br /> Owner's Name Phone F/,3,,P' 7�6_ <br /> Address City <br /> Contractor's Name " License Phone C� <br /> _ w i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 ! <br /> 1 PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT . /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAaNKf✓ SEWER LINES/�4� � PIT PRIVY _.Z <br /> SEWAGE DISPOSAL IELCESSPOOL/SEFPAGE PIT OTHER <br /> PROPERTY- LINE IRI.VATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED"qSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indu`s•triai Cable Tool Dia. of Well Excavation <br /> 4,----Domestic/private Drilled Dia.. of Well- Casing <br /> Domestic/Public Driven Gauge of Casing <br /> !Irrigation ,, Gravel Pack Depth of Grout Seal <br /> Cathodi.c._Pr_otection _ Rotary Type of Grout <br /> Disposal Other Other Information L ; <br /> Geophysical, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - �c.�l ,. �— ..., 7f A) <br /> Type of Pump -- - `- - -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR: / / . State, Work Done <br /> � 'gg r <br /> DE9�!`RUC ION -OF. WELL:. Well-Diameter - Approximate Depth 5 <br /> 1 Describe Material and Pr cedure <br /> I hereby agree to comply wif9h all laws and regulations of t e 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 /> information. is true to est of -my- knowledge and belief, I WILL CALL FORA GROUT-INSPECTION <br /> PRIOR TO GROUT NG AN_D 4,rFI IO.N, <br /> SIGNED _ TITLE it <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I µ <br /> APPLICATION ACCEPTED Y DATE /C-)47 <br /> ADDITIONAL COMMENTS: <br /> PHAS.E ,II GRO T -INSPECTION HASE III FINAL INSPECTION <br /> INSPECTION BY DATE ► ? 7 INSPECTION BY DATE <br /> - P - Gwl,V*f 1/77 _ 2M� <br />