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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fr FICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6_6_710 <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 Sawn Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /.Z U_�.k.(! S' ��EKG lQn� �� CENSUS TRACT <br /> y� r <br /> Owner's Name 00FR40,e AJA Phone <br /> Address Citp Ca <br /> Contractor's Namec�7//yWge License i / one ey4 2-74 6 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_J PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMSTIC-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 — t <br /> Domestic/public Driven Gauge of Casing - <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: Contracto�t!��`/ - �^�' <br /> Type of Pump R.P. <br /> PUMP REPLACHMBNT: Lk/ State Work Done :-L�A? pla egz 2 /-off 421-,,0a z-f-'1 174 hILA�d <br /> PUMP :REPAIR: L7 State work Done <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 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 thewell in use. The above <br /> information is true to the best of my.knowledge and bel4ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG G AND AINAL INS N. <br /> SIGNED <br /> fA D p PWOr ON REVS SIDE <br /> R D <br /> �TMENTUSE ONLY <br /> PEASE I <br /> SPPLICATION ACCEPTED DATE—ADDITIONAL COMENT6: - <br /> PHASE II GROUT INSPECTION PHAS IIF INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> =E H 1426 Rev. 1-74 - _ _ ____ 1-74 2M <br />