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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]J-9'6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7,7 <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 Joaquir <br /> -county Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> j OB ADDRESS/LOCATION S h 3 3 eel, r�' i7 ��� ��t~ CENSUS TRACT <br /> — <br /> wner Is Name —%,.,J okp -.r ,vTi sPhone <br /> Address ean(r ACPi...t.01r c City �tdN -t j7` <br /> ontractor's Name 1_1A�' 7 jZeIC5 n 4 /nr j ,.y OQ4 Az License #2t1_,,j,1c,1 Phone <br /> YPE OF WORK (Check) : NEW WELL / / DEEPEN_/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /. <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 6 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �— Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal R <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor IAF-t&,el? S•.af ac•".•- Ij A/t-J Svi?e/ l r <br /> Type of Pump , �y H.P. <br /> v <br /> UMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done Acid ta„e <br /> ESTRUCTION 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 /> 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 /> ELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> ,nformation 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 /> IGNED c rP.A t TITLE„Z� ,wt <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> 1/77 7M <br />