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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> FO&,;OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Q <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE J SSUED Date Issued e-43- <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. Ordtnance No 1862 and the Rules and Regulations of. the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a o�-r �v� �er ENSUE TRACT <br /> Owner's Name p Phone ' <br /> Address 'I fJ, o � <br /> City <br /> Contractor's Name License # . u hone Ly- 6 <br /> s i.. '.' .... <br /> TYPE OF WORK (Check): NEW WELL J-7 DEEPEN/ T RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION '/—/ PUMP REPAIR -/W—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 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 CONSTRUCTION SPECIFICATIONS <br /> �. Industrial Cable Tool Dia.. of Well Excavation <br /> DomesticJprivateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth tof Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information { <br /> Geophysical Surface Seal Iristalled 'B <br /> PUMP INSTALLATION: }Contractor <br /> Type .of Pump =4ei H.P. _ <br /> PUMP REPLACEMENT: .. State Work JDone <br /> i <br /> PUMP .REPAIR: / / State Work Done Gj(z.�-rc S Cdr + <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 weil ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a A <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. ..lcnowledgea d belief. I WILL CALL FOR-A -GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSP I <br /> SIGNEDa, ITLE ,r�S . <br /> D PLOT PLAN ON REYRRSE SIDE <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE I - 1 <br /> AP ILP CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: F E <br /> PHASE II OUT15SPECTION PHASE IIi FINAL INSPECTION <br /> INSPECTION BY DATE T INSPECTION BY DATE 9-10-76 <br /> E <br /> A4426 ' Rev. 1-74 <br />