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7 !�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. $G/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /Z-9 7U5 <br /> i (Complete In Triplicate) <br /> Application is hereby msde to 'the San Joaquin Local health District for a permit to construct <br /> and/or .install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 1862 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name V-1 1 ® Al Phone ' <br /> Address YY 0 Y, r 9 9 City L32;1 r`. . <br /> Contractor's Name License Phonal ) <br /> TYPE"OF WORK(Check): NEW WELL / � DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR/ 7 PUMP REPLACEMENT /7 <br /> Other <br /> T_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELLI <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; <br /> Industrial ----Mble Tool Dia. of Well Excavation /`Z, �! <br /> [---Bomestic/private Drilled Dia. of Well Casing �} <br /> Domestic/public Driven Gauge of Casing Z26 ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout a C- c <br /> Disposal Other Other Information- <br /> Geophysical 3 Surface Seal Installed By:- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .. H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> i�.;.� ,.-- " : _te -.-.`Wor. -: <br /> / / St� � -ic`Done- <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth <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 <br /> after completion of my work ox a new well,, I will furnish the San Joaquin Local Health District a ; <br /> WELL DRILLERS REPORT of the well and notify them before putting.the. well. in use.... The above <br /> information is true to the-hest.of'my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO GROUTING AN FINAL!INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE 42- L TJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION C., PHAS511IIPPINAL ISSPE <br /> INSPECTION BY DATE /.-Z // INSPECTION BY 'f DATE f <br /> E__H. ' f- Y . _ r 4/75 2M <br />