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Gt�t i b� (Oft /0, '� SAN JOAQUIN LOCAL HEALTH DISTRICT ----- ^ <br /> F094OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS.PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued 9_s_77 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> .JOB ADDRESS/LOCATION ,3 018' �. (R.' � �, �, CENSUS TRACT <br /> Owner's Name - „.._,_ Phone <br /> Address _ 3 }8'l � �R,-'..:.... �4,01 4W. City <br /> Contractor's Name License # lf37h1'�Phone y-274 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN '/7 RECONDITION /- . DESTRUCTION /_7 i <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT .F <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 4 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 /> I Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done . <br /> PUMP 2EPAIR: /7. State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <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 any 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 d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR- 19,,MUTING AN A FINAL JUPEC%N. <br /> SIGNED 'TITLEP-rinox , <br /> W <br /> PLOT PLAN ON 1MVERSE SIDE <br /> FOR TMENT USE ON Y <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I I FI INSPECTION <br /> INSPECTION BY DATE INSPECTION B ATE' <br /> t i E H 1426 Rev. 1-74 1-74 2M <J <br />