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SAN JOAQUIN LOCAL. 9ALTH DISTRICT , r/z/ A/a >t 53, <br /> FOR-OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif/b/W iermit <br /> Telephone: (209) 466-6781 /�O3W- !a 7 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT No. �7 7 <br /> • I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-06-77 <br /> { / I <br /> �� (Complete In Triplicate) <br /> 7 ' <br /> Application is tereb made to the San Joaquin Local Health District for a permit to construct f <br /> and/or install the work herein described. This application is,-made in compliance with San Joaquin <br /> County Ordinance No'. 1862 Arid the Rules and Regulations of the San,Joaquin Local Health Distract. <br /> _ .t <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT <br /> Owner's Name R: � 'r Phone ' a <br /> Addressf City` Cet,12,u <br /> Contractor's Name OZ A/t, License it j/ e Phon <br /> IM.. � <br /> TYPE,OF-WORK(Che_ck)-:ANEW- ELL .- DEEPEN'/T/_'�iRECONDITION�/_-;;;�nS.TRUCTION--/ a <br /> PUMP��iNSLATION„/_/ PUMP REPAIR__/_,/ PUMP REPLACEMENT /7 <br /> &A kOther <br /> M s II <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER LINE PIT PRIVY <br /> SEWAGE DISPO AL FIELD., - CESSPOOL/SEEPAGE PIT r- OTHER <br /> PROPERTY LINES PRIVATE--DOMESTICf,WELL /&! PUBLIC DOMESTIC WELL <br /> INTENDED USE 1YPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private IM Drilled -a,,Dia­of-Well Casing <br /> Domestic/public IM Driven Gauge of,,, Casing - <br /> Irrigation 11: Gravel Pack Depth of Grout Seal <br /> Cathodic Protection .4. Rotary Type of 'Grout ,r AA <br /> Disposal IM Other Other, Information Ftu.f <br /> Geophysical LyII Surface_ 'Seal Installed_ By: <,, F�cs n.v <br /> E PUMP INSTALLATION: Contractor <br /> TypeofPump H.P. . . . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:.. /. / ..State Wark,Done. <br /> W. �--�----».,.,.�,. — ..�.. w�. <br /> DES-TRU.CTION OF WELL: Well 'Diameter Approximate Depth I <br /> °° ,Describe aerial and Procedure <br /> Ble6L/r� <br /> I hereby ag.�ree t comply wit all laws nd regulations of the San Joaquin Local Health Distriet <br />� <br /> and the State of California ,pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work lion a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thewell and notify them before putting the .well in use. The above <br /> information is true to t b1F tXeCTION. <br /> knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T IN ANDA N I <br /> SIGNED k, TITLE <br /> (DRAW PLOT PLAN .ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> II ' <br />. APPLICATION ACCEPTED BY I 44, DATE *77 <br /> , A 4� e-_ <br /> ADDITIONAL COMMENTS; :IM <br /> PHAS GRO T 'INSPECTION PHASE ILXFIN4 INSPECTIO <br /> INSPECTION BY104 1 AMA114 <br /> DATE /0//5 `7 7 INSPECTION BY DATE yD Q�7d� <br /># E H,1426 Rev. 1-74 <br />