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a <br /> •= .. dC� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif. --77 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Za_9ou al <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7.n,7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit ti construct <br /> and/or install the work heroin described. This application is made in compliance iith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local H�:alth District. <br /> JOB ADDRESS/LOCATION Al - J�llJl 1l^�_D/�2f 7[Il (11��K SUS RAIT <br /> Owner's Name _llaiL. <br /> ✓ -/ <br /> Address /5- /7C) �7 �^ /c-)/tau .//�/J.� City. <br /> Contractor's Name ' r�.�17! �hn ( P,�,,._.t.'._. License C .Q4in Phoc.e ,572—/03/ <br /> TYPE OF WORK (Check)- NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION 1-7 PUMP REPAIR/-7—PUMP REPLACEMENT f7 <br /> Other L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD &aslt CESSPOOL/SEEPAGE PIT _ OTH1:R <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (, <br /> Industrial Cable Tool Die. of Well Excavation �L' <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> -- Domestic/public _ Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout SealT <br /> _ Cathodic Protection Rotary Type of Grout iA <br /> Disposal _ Other Other Information - <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ' <br /> • <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4v PUMP '.REPAIR: /=7 State Work Done <br /> .I. <br /> l <br /> ION OF WELL Approximate Depth <br /> DESTRUCT <br /> Describe Material and Procedure \ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District: <br /> aid 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 <br /> WELL 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 TOGBOUTING AND,A HNAL ZN ECT IO . // / <br /> SIGNED (� TITLE L -L 2 <br /> tuMvf PIAT IPTYN ON REVERSE SIDE) <br /> �) rcm DEtPARTMENT USE ONLY <br /> PHASE I ! /�/ �, DATE <br /> APPLICATION ACCEPTED AY 1Z� z�� <br /> .1JDITIONAL COiRDZiTS: — ,rfPj2 �1.�,[QJ'��'�'(;�- .+� <br /> PH.1S II GROUT IN PECT30N PHA II IN INSPACTI N � <br /> INSPECTION B1-::4- DATE � � J INSPECTION BY TE <br /> E H 1426 Rev. 1-74 4/75 2M <br />