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+ +' SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE-OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '•77-93 1 ,/ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ? <br /> ` (Complete In Triplicate) ; <br /> Application is tereby made to the San Joaquin Local Health District for a permit to construct ' <br /> and/or i1nstall the work herein described. This application is.made in compliance with. San Joaquin ` <br /> County �dinance No. 1862 and the Rules and. Regulations of the San Joaquin Local Health Distr�c t. <br /> JOB ADDRESS/LOCATION C CENSUS TRACT <br /> Owner's Nameone a <br /> Address City EK r l <br /> Contractli s NameNIE rl 10 L& lLicense #&S 4 ! <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL ' / DEEPEN '/—/ RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /�. <br /> Other — <br /> DPISTANCE TO NEAREST: SEPTIC TANK Q ' SEWER EINES PIT PRIVY r 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT --- OTHER <br /> PROPERTY LINE =PRIVATE DOMESTIC.WELL PUBLIC DOMESTIC WELL <br /> .INTENDED .USE TYPE OF%WE L <br /> _ L CONSTRUCTION SPECIFICATIONS <br /> i <br /> Industrial _ Cable Tool "Dia, of Well Excavation <br /> _ Domestic/private. Drilled Dia, of Well Casing <br /> Domestic/public–,., .�_ �._ Driven Gauge of Casing t <br /> 42 a <br /> Irrigation Gravel Pack Depth of Grout Seal Sd <br /> ' Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed B : r� <br /> PUr INSTALLATION: Contractor •�Ate_ <br /> Type of Pump - y H.P. <br /> PUMP REPLACEMENT: / / State Work Done tS9 <br /> PUMP .REPAIR: / J State Work Done"-W' <br /> DESTRUCTIZON OF WELL: Well Diameter , r Approximate Depth <br /> Describe Material--::and,.Procedure � 1{I <br /> I hereb IIa ree to com 1 with all <br /> Y g P Y 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. my work on .a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of theUijl nd not' y thein before putting the .well in .use. The above <br /> information is true to the bm wledge"ana belief. I WILL CALL FOR A GROUT ,INSPECTION ' <br /> PRIOR Tii AN FIN N. 1 <br /> SIGNED TITLE <br /> PRAW PLOT PLAN ON REVERSE SIDE f <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE-_I__1 <br /> APPLICATION -AC EP <br /> TED., BY.. <br /> DATES-77 , <br /> ADDITIONAL COMMENTS: i <br /> P. I iGRO INSPECT:0_N__ PHASEmI]?I/FIWL INSPECTION <br /> INSPECTION BY ' DATEr141INSPECTION B DATE / 2� <br /> �a I <br /> E H 1126 Rev. 1--74A�: > <br /> lf. 7 � ' <br />