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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOR OFFICE USE.: �t 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued p-,V-1 <br /> a-AA 3 7 7 (Complete In Triplicate) <br /> Applicat' n is hkseby 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 .t Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CSUS TRACT <br /> R <br /> Owner's Name Phone <br /> Address � <br /> Cityptr� <br /> E <br /> * ' <br /> Contractor s .Name Licens.e i/ .Phone. -- <br /> TYPE OF WORK' (Check) : NEW WELL -•. DEEPE % _ 'j <br /> _ N_ /•e RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP' REPAIRS/ / PUMP REPLACEMENT /_7 <br /> Other / / J ; r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE PIT PRIVY 'i , <br /> SEWAGE DISPOSAL FIELD- CESSPOOL/SEEPAGE .PIT BOTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL 1 CONSTRUCTION SPECIFICATION <br /> Industrial Je Toolj� 4a Dia, of Well Excavation d k <br /> Domestic/private ,. Drilled Dia. of Well Casing <br /> Domestic/public '�' Driven Gauge of Casing - <br /> rigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' I <br /> Geophysical '• - Surface Seal Installed By-' <br /> � <br /> PUMP INSTALLATION:j Contractor <br /> Type of,- Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> " <br /> I hereby agtee to comply with all laws and regulations of the San Joaquin Local Health. Distr—ct <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 7A �� <br /> WELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above <br /> information 's true to the t of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TOG U IN TNbe AN A FNS CTION. <br /> SIGNED TITLE <br /> V.XAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION- ACCEPTED .BY - DATE j9-26—'. <br /> 9-26' <br /> ADDITIONAL COMMENTS: _ i k <br /> __P,HASEXII--GROUT-INSPECTION— " PHASE SII-/FINAL­°'INSPECTION-- <br /> INSPECTION BY DATE INSPECTION BY /1Xj DATE /) - 7 -- <br /> E <br /> ATE /) . 7 •E H 1426 Rev. 1-74 1177, 2M <br />