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IP <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F <br /> OF. OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;?Z-9µ,m <br /> l THIS PERIMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ApplLcation 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 t*oe Rules and Regulations of the San Joaquin Local Health District. <br /> !OB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name {i, rte_ C t Phones JQ -4/ge <br /> Address _,�. 3 $ j Lv.t i y �'�► City <br /> Contractor's Name f L i_h(i Cwt "S License Phone <br /> TYPE OF WORK (Check) : NEW WELL /y/ DE1,PEN /_7 RECONDITION /_-T DESTRUCTION /7 <br /> PUMP INSTALLATION /P- PUMP REPAIR /_/ PUMP REPLACEMENT L7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK (, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINT: - 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 Drilled Dia, of Well Casing _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ✓ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> geophysical Surface Seal Installed By: z <br /> PUMP INSTALLATION: Contractor /�u i , ,,�, o•� -��' i �� !': y, <br /> Type of Pump 7�,.•/��'..� r <br /> _ ,,LSI' :! •� _-; �.fl.. �, c- ,,� / f+/�r'7 f c)..! ,�� ,_� :�"•,; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done ;' + <br /> /777 <br /> INSTRUCTION OF WELL: Well DLameter _`� Appr ximate Depth G ..? <br /> Describe Material and Procedure �•<„' <br /> 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 r ' <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a ��I# <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 />-PRIUK TO GKO C AND F . A1. INSPBCI ION. <br /> SIGNED, TITLE (r; , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A1'l'LICAT10N ACCI:P'PED BY DAT <br /> ADDITIONAL COMMENTS <br /> PHASE: I GROUT INSPECTION PHASE I2 FINAL INSPECTION +: <br /> INSPECTION BY DATE INSPECTION BY N.i+✓/i DATE �.. S” �• <br /> 6/77 Q52m 7e, <br /> F 11 1426 Rev. • 1-74 <br />