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SAN JUAQUIN LOCAL HEALTH UIS'P1t1C'T <br /> FOR _gFFIC!� USE: 160:x. Hazelton Ave. , Stockton, Cal: ���c41 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27 2*f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-1s-717 <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 Cf'?x�� 1j« �� r � a CENSUS TRACT <br /> Owner's Name �.� v // tzAzI AyP b Phone <br /> Address _CL70'3 �` ,C/uP OA City <br /> Contractor's Namernn l��N/L ,/����}J License Ify �Phone <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN / / RECONDITION /7 DES'TRUC'TION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKR LINES PIT PRIVY Xe)X <br /> SEWAGE DISPOSAL�FIELD .�d CESSPOOL/SEEPAGE PIT d n •M OTHER &4_PROPERTY LINE&�RIVATE DOMESTIC WELL/_ PUBLIC DOMESTIC WELL EE1lsUC <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial _X Cable Tool Dia. of Well Excavation .4;711 <br /> _ Domestic/private Drilled Dia. of Well Casing ;:, ii <br /> Domestic/public Driven Gauge of Casing 11 f c�aci� <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout (t ,an rav <br /> Disposal Other Other Information Y' <br /> Geophysical Surface Seal Installed By: e4yne - � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter J �� CIJEL�QTlo Approximate Depth _ <br /> Describe Material 4nd Procedure _ <br /> Old weLL cies P �� � �� - � �.�J 7 J > <br /> I hereby agree to <br /> a col ly wit as 1 law and regulations of the Si Joaquin Loc 1 Hea th Dib i <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 is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING OND OeF%L INSPECTION. <br /> SIGNE �� t TITLE CC —G1�c 1y r�I� 3 <br /> (DRAW PLOT PLAN ON REVERSE SID _ <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I � �} <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _2 �/�- �� <br /> E H 1426 - Rev. • 1-74 I <br /> 6/77 , 2M <br />