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&1 1, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zy-s/61d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7_ p <br /> (Complete In Triplicate) <br /> `pplication 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1OB ADDRESS/LOCATION S I �c n OJ .-7,n._r ALng ;Aeg CENSUS TRACT <br /> ,mer's Name Cr u,. � , %tn,yr, Phone ''fie S-15,9, <br /> Address a y5o E � (� City baliddk <br /> G 5`4" <br /> `:ntractor'e NameLicense # d d Phone <br /> _CPE OF WORK (Check) : NEW WELL/ / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /—j <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other /_/ <br /> aiSTANCE TO NEAREST: SEPTIC TANK Z2T SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G <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 U <br /> Domestic/private Drilled Dia. of Well Casing J.5 <br /> Domestic/public Driven Gauge of Casing �� Qm4 ; E C <br /> Irrigation Gravel Pack Depth of Grout Seal A-A <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> W INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> -W REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /% State Work Done <br /> [ STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rid 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 /> 17LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> _`formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> crGNED u�.'k PDn/Mto\ TITLE _(Ytx.�w6.a <br /> (DRAW PLOT PLAN ON REVERSE SIDE) —� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> PLICATION ACCEPTED BY �,.! DATE <br /> aBDITIONAL COMMENTS: <br /> P IZ 9foUTJNSPECTION P III INAL INSPECTION <br /> SPECTION BJC ATE 21/76 INSPECTION BY DATE <br />