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G1l SAN JOAQUIN LOCAL HEALTH DISTRICT <br />i FOE OFFICE USE: 1601 E. Hazelton Ave,, Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.���4/ <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />I (Complete In Triplicate) / � / - 23r --I <br />Application is hereby made to the San Joaquin Local Health District for a per6�it to construct <br />and/or install the work herein described. This application is made in compliance with San Joaquin <br />County Ordinance NQ. 1862 and�the <br />�Rules <br />p and Regulations of the San Joaquin Local Health District. <br />( l 0 vV .�GL.�✓L.� <- -ems <br />JOB ADDRESS /LOCA Ia�f %� Y�CJi� � � CENSUS TRACT <br />Owner's Name(' !� <br />—rte-- -�� Phone <br />Address ✓ C�_b 6 5 - <br />Contractor's NameL <br />}�^/'� <br />License`-'�73Phone / V'2 37a <br />TYPE OF WORK (Check): NEW WELL 40 DEEPEN /-% RECONDITION j% DESTRUCTION �f <br />PUMP INSTALLATION V' PUMP REPAIR / / PUMP REPLACEMENT /% <br />Other <br />DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY e <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEP�GE PIT OTHER <br />PROPERTY_ LINE - PRIVATE DOMESTIC WELV4�" `�LIC DOMESTIC WELL <br />USE <br />Industrial <br />Domestic/private <br />Domestic/public <br />Irrigation I <br />Cathodic Protection <br />Disposal <br />Geophysical <br />PUMP INSTALLATION: <br />+ PUMP REPLACEMENT <br />PUMP.REPAIR: <br />WELL <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />-� Rotary <br />Other <br />I <br />Contractor <br />`Type 'of Pump <br />_ 1 <br />'State Work Done <br />_. ; State Work D n <br />DESTRUCTION OF WELL:Wel Diameter <br />De ribe Mate <br />CONSTRUCTION SPECIFICATZONS (� <br />Dia, of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout --Se <br />Type of Grout L "T` <br />Other Information <br />Surface Seal Installed By: <br />imoor <br />H. P. <br />pyo ma th Ivo <br />I hereby agree to comply with all la 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 />i 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 />PRIOR TO GROUTING AND A FINAL INSPECTION. V1 <br />SIGNED T -J.,- I_ }} . (l _. TITLE -),),n,,.,.. _ 1 1,1J <br />-DEP <br />PHASE I <br />?LIGATION ACCEP <br />,DITIONAL COMMENTS <br />PHASE II GROUT INSPECTION <br />INSPECTION BY IV1 DATE <br />E H 1426 Rev. 1-74 <br />NON REVERSE SIDE <br />,TIRT USE ONLY <br />iAIAVCU <br />PHASE <br />INSPECTION BY <br />DATE <br />AL INSPECTION <br />ATE _ <br />3/76 2M <br />ialand <br />Proced <br />H. P. <br />pyo ma th Ivo <br />I hereby agree to comply with all la 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 />i 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 />PRIOR TO GROUTING AND A FINAL INSPECTION. V1 <br />SIGNED T -J.,- I_ }} . (l _. TITLE -),),n,,.,.. _ 1 1,1J <br />-DEP <br />PHASE I <br />?LIGATION ACCEP <br />,DITIONAL COMMENTS <br />PHASE II GROUT INSPECTION <br />INSPECTION BY IV1 DATE <br />E H 1426 Rev. 1-74 <br />NON REVERSE SIDE <br />,TIRT USE ONLY <br />iAIAVCU <br />PHASE <br />INSPECTION BY <br />DATE <br />AL INSPECTION <br />ATE _ <br />3/76 2M <br />