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SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> Iwo USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ! Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Js-/,� s-lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Is'sued fL-7-75 1 <br /> (Complete In Triplicate) <br /> Application is hereby made to,.the Sen 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 N0.11862 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> �r nn�4L Hr/e S 62 ,,- <br /> CENSUS TRACT <br /> Owner's Name 2riL7r G�`i l � SL Phone n f / <br /> Address t S i S City (1-0,044 <br /> n 1 s <br /> Contractor's Name . License 11./ Y hone 1 G7G I <br /> 'M N1 <br /> TYPE OF WORE (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /7 DESTRUCTION rT <br /> PUMP INSTALLATION L7 PUMP REPAIR 07PUMP REPLACEMENT /_T N <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 /> _ Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> i _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical rSurface Seal Installed 89: <br /> PUMP INSTALLATION: Contractor CYC <br /> oe�sis ao-y�� Type of Pump `Tet -A H.P. <br /> PULS REPLAC6pfffi�P: L7 State Work Done <br /> i <br /> PUMP :REPAIR: fZC7 State Work Done C R7 c- S��2 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Matarlal-'ah4_Piocedure <br /> I hereby agree o?comply-with-dI1-_1Wws 5snd regu ationa of the San Joaquin Local Health District <br /> and the $tete..of-Calitornia:pertaining.-to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a�neit well , Irwi314'furniah-the San Joaquin Local Health District a <br /> WELL DRILLERS-aEPORT A the:wellSAxid -notif"th_em-�before ,w <br /> Nputting the well in use. The above <br /> information is tr`de to the beat of my d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOG Ih <br /> AUTING.AN <br /> R TO> �FINAL S I <br /> SIGN ti ITLE /p- <br /> ' ". RAW- PLAN ON= 8 SIDE <br /> r' •.7 .T �_P;. .. *�_FORrDZPARTMENT USE ONLY <br /> PHAS&.I' Y /J <br /> KATION"ACCEPTED BY � ' = c ` DATE 7 <br /> AVwiTIONAL COMMENTS: 'Afi \ r -% � : y, YY--" <br /> PHASE II.GROUT INSPECTION PHASE II FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE47(A S <br /> E 9 1426 Rev. 1-74 J �_�� 7m <br />