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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR OFFICE USE � 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> / APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '��"�p7 <br /> I` <br /> THUS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued _6130/71 <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 An "compliance with San Joaquin <br /> County.,.Ordinance ,No.,,,1862 and the Rules and Regulations of the San Joaquin Local Health Dist#ct. <br /> e :�.'�(;! " • i.t.CC +2 Y� i4vE �'�J Z.ZS- <br /> JOB ADDRESS/LOCATION I1. __ CENSUS TRACT, <br /> �/�2 N lE 12 /fEN�SliQ N �Il� / <br /> Owner's Name ' �}��� `j ,� Phonef�^� <br /> Address L2 oil 4.4A City 1-4-sr,t-16.44 -- <br /> Contractor's Name LIZ <br /> License 4TZKZZy Phone <br /> TYPE OF WORK (Check) : NEW WELL -7DEEPEN/ / RECONDITION /� DESTRUCTION <br /> PUMP1I;INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _4 SEWER LINES,,(W PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ... CESSPOOL/SEEPAGE PIT --- OTHER — <br /> PROPERTY L_INEAO PRIVATE _DOMESTIC WELL�-t PUBLIC DOMESTIC_ WELL <br /> INTENDED USE ILTYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia, of Well ExcavationS! '� <br /> Domestic/private Drilled Dia, of Well Casing '> t <br /> Domestic/public I Driven Gauge of Casing . � __ __ Y <br /> Irrigation I Gravel Pack Depth of Grout Seal I . <br /> Ii <br /> Cathodic Protection N. Rotary Type of Grout <br /> Disposal .I� Other Other Information N( f <br /> Geophysical Surface Seal Installed By: <br /> PUMP _INSTALLATION. Contractor <br /> Type of Pump -- rir.�,- �.-e - H.P. ? s m <br /> PUMP REPLACEMENT: / / State -Work Done <br /> r PU1+�P-REPAIR: / V State Work Done T " _ .F W I <br /> fDEs.'rRUCTION OF WELL: Well, Diameter Y Approximate Depth <br /> A Describe Material and Procedure, <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Di.stri� + <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 no ify them before putting the .well in use. The above <br />` informatio s true`' o the s f owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G AFI SP } <br /> SIGNED <br /> T DRAW PLOT PLAN ON REVERSE SIDE) T <br /> FOR DEPARTMENT USE ONLY <br /> PFk51SE I <br /> k APPLICATION ACCEPTED-BY -. - - � �`- .. -- � .-- DATE <br /> ADDITIONAL COMMENTS: 14 / <br /> PHASE II GROUTITINSPECTION _ P_ SE ) 7FINAT.INSPECTION <br /> ' INSPECTION BY (DATE INSPECTION BX DATE 2 <br /> � •�� + n � r 2M <br /> 4 E H 142 9f77 Rev. 1-74 '� =� <br />