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SAN JOAQUIN LOCAL HEALTH DISTRICT p/L5 <br />+ FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,-/4p <br /> —/�q, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l � <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> f and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa uin Local Health District. <br /> E ,TOB ADDRESS/LOCATION S�� �.�� �� 1��� ��+� CENSUS T <br /> ti RACT <br /> Owner's Name c- otiJ Phone ��'�- IVL 4, 1 <br /> `'p p - <br /> Address 1 b�.5, Wes* ; o-,,—- ot. City b t� <br /> Contractor's' Name a ;� Ze 0-v License 4�3� �s Phone,,S 3-VS <br /> { <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP ,INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> Otherl-/-7 <br /> :i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE}DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER `v <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 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_:_ <br /> PUMP INSTALLATION: Contractor A.)4- 0,,,�, y i; ,� o <br /> Type of Pump I -Cb:r. e. H.P. Vo S . <br /> L e- <br /> PUMP REPLACEMENT: <br /> /�/ State Work Done �,,& ;,L 'ne,,,)_T�Wi 0 "u! nus5� ��� :►tiq,��,c� <br /> f PUMP REPAIR: / / State Work Done <br /> DES-TRUCTION 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 Di-stric-t} <br /> and the State o.f 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 /> 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. I <br /> SIGNED 7 TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR <br /> IDE) —FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II NAL SPECTION - <br /> INSPECTION BY DATE INSPECTION BY TE -- <br /> E H 1426 Rev. 1-74 �%� / 2M <br />