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' Z6"o,Ii a ,0v SAN JOAQUIN LOCAL HEALTH, DISTRICT <br /> FOE, OF ICE USE: �/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�//84//84 <br /> i . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I <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 Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION Za D4::f"�� //4)1/4f"kloaGP %449 •4t� j)/njXeejW ENSUS TRACT �S <br /> Owner's Name Phone <br /> Address / lL6.Z pj It A-2 Xo/wCity S�O� <br /> Contractor's Na pyt c License U! ,3-7XJ�Phone t L 7L i <br /> t <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other d / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation. <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . I Rotary Type of Grout <br /> Disposal f Other Other Information <br /> Geophysical 1t} Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type,of Pump Tie✓d tt _ H.R. <br /> PUMP REPLACEMENT: 'State Work Done <br /> PUMP�.REPAIR: -`State Work Done/./��ryb /d�' `�►� 'Ia:r Ca�lGAoua <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j I 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 anew 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 ofO <br /> know1 dg d belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO G OUTING AND A FINAI! INSPICTNN <br /> SIGNED TITLE -ea-r . <br /> W PLOTPLAN ON F&VERSE SIDE F ^S <br /> FOIt4D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT�BY /GO DATE <br /> ADDITIONAL COMMENTS: `'1 <br /> PHASE II GR UT .INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 76 <br /> ,I <br />