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/r SAN JOAQUIN LOCAL_ HEALTH DISTRICT r <br /> FOR OFUCE U ;E: 1601_ E. Hazelton Ave. ,:,-,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 7Sy ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u Date Issued a-2,7-72 <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District fora 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 /> JOB ADDRESS/LOCATION f �624Av/zeNSUS TRACT <br /> 4 <br /> Owner's Name Phone <br /> Address &_x-/,( City <br /> Contractor's Name License �o ss�a� Phone __141,P_11 <br /> i <br /> TYPE OF WORK. (Check) : NEW WELL / DEEPEN /. /: RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> { M. <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> —� Domestic/private Drilled Dia, of Well Casing S`/,�'� _ v <br /> -Dome'stic/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 <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:' / / State Work-Done <br /> DESTRUCTION OF WELL; Well Diameter OG® �� L- 7"-V proxi De <br /> - -- <br /> Describe Material and Procedure _ <br /> I hereby agree to comply with all laws and"regulat fons-of-the-San Jaaquin._Local- lie•a 7th- istrict <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 /> 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 NAL INSPECTIO <br /> SIGNED TITLE 1.= <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />' APPLICATION ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JII/FINa INSPECTION <br /> INSPECTION BY DATE //-/Gy- 77 _ INSPECTION BY DATE 2 -- L_ <br /> � � �- 1177 214CO <br />