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e✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70--r,--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-BLAS Lc1 <br /> 76 -t/ sr� <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 ADD SS/LOCATION N Lo C,,ezn14 hC Atfe CENSUS TRACT 22SY r , <br /> Owner's Name _A�_�a5 Phone 572-4--7 <br /> Address IY5 Ai a►N Et-::.cA-Or j CQ . City 4 <br /> Contractor's Name t►rsWtC_ WG�[j- I" L-0 . Iry c- License # 2/0 Phone-.S?- 2-`7� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / J DESTRUCTION �. <br /> PUMP INSTALLATION Z PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F 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 /> __ �k Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal SD ' <br /> Cathodic Protection --7 Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: CoN-772atcSQk— <br /> PUMP INSTALLATION: Contractor p{�j� ll�C-ti q 1:�,QUAP C, b'.,- <br /> Type of Pump S c L91,R P-7a s) tac c . H.P. -7 V) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done fit' <br /> DESTRUCTION OF WELLC)I(Well Diameter r, Approximate Depth 30�T. <br /> ` ,, , Q Describe Material and Procedure <br /> 11rareby 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 /> afi,er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WttL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN AND A FININVSPECTION. <br /> SIGNED TITLE -.54L,�j-S Alr=7fl <br /> DRAW PLOT PLAN ON RE EkSE SIDE^ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ¢� ��,�;' �„ DATE <br /> ADDITIONAL COMMENTS: <br /> P OUT INSPECTIqN PHASY, III NAL INSPECTI N <br /> INSPECTION BATE 191 INSPECTION B DATE <br /> E H 1426 Rev. 1-74. <br /> 3, 76 2M <br />