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v -N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 2. Hazelton Ave. , Stockton, Ca_ _ . <br /> Telephone : (209) 466-6781 <br /> 1PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> /AF <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -j_/f-7J <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 ADDRESS/LOCATION 4ZZ50 �EF�1 vrV CENSUS TRACT <br /> Owner's Name Phone 4�jZ- --7(0j <br /> Address City <br /> Contractor's Name . J L u I License IIGPhone 3S1 - Lct65 <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN_/ / RECONDITION / / DESTRUCTION Yf <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> PUMP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK'25_Q SEWER LINES �C;_-QPIT 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 /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing n <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information \ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor \C' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> — r <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ri n/ /f jJ OfcJYt - Approximate Depth <br /> Describe Materia and Procedure <br /> c9. r Tl�cs ! 5 14 tf / r ��e �tk e r ✓ tr: <br /> I iereby agree to comply with all laws and regulat ons of the San Joaquin Local Health Diiftrict <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 truel Q the , est of my knowledge ad belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G� fy{ INSPECTION. r <br /> SIGNED TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDEµ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J <br /> APPLICATION ACCEPTED BY E l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P NSPECTIO�N <br /> ON <br /> INSPECTION BY DATE INSPECTIS B/- DATE — / <br /> - - /.'/ j 3/76 2M <br />