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_ _ SAN JO.AQUIN LOCAL HEALTH DISTRICT <br /> _OL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 'APPLICA'TION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No. Z <br /> .. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -j7-7� <br /> (Complete In Triplicate) <br /> ,plication is hereby made to the San Joaquin Local health Diatrict for a permit to construct <br /> ,,-.d/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> C3C fIG��C%L•) V+C/V'_' d <br /> _`B ADDRESS/LOCATION c� C, -) . 4eLt f"rcy_k Vf• lelk",ti 64o' , CENSUS TRACT <br /> r ner's Name (! i FCc�s2�' __ r -:.c�.� • Phone ' , <br /> Address / S 7U q iCJ %2 C City /C"'o <br /> ntractor's Name SCH JOdqL-E53 Pmrnrp Cn, License # Phone � <br /> ,vssson of an ocgasn a p ur ...o., <br /> PE OF WORK (Check) : NEW WEL `' TT E til /_% RECONDITION ;�/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /F4 PUMP REPLACEMENT /_7 <br /> Other / / -- <br /> [ `STANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation \ <br /> Domestic/private y Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information t� <br /> Geophysical Surface Seal Installed By: <br /> INSTALLATION: Contractor N <br /> Type of Pump H.P. n <br /> r <br /> 'UMP REPLACEMENT: / / State Work Done -- -� <br /> .REPAIR. /17-"State Work Done 7-tiS4ci�� <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material a.nd Procedure <br /> 'zereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> . i the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .tomer 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 /> :ormation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .eOR TOG TING AND A FINAL INS CTION. <br /> IGNED TITLE sot`s 3' eq Baa Purni Co. <br /> r� C , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) s" ����}�`r `� <br /> iS 7 Zi et,• `x'}' <br /> FOR DEPARTMENT USE ONLYRME <br /> HASE I r F., 3a240 <br /> 71LICATION ACCEPTED BY DATE �{ L• <br /> )ITIONAL COMMENTS: _- <br /> PHASE I GROUT INSPEC ON PHASE I I/FINAL INSPEC ON <br /> �TcPECTION BY DATE IN BY k DATE <br /> H 1426 Rev. 1-74 ►. /7C oa,r <br />