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SAN JOAQUIN LOCAL HEALTH DISTRICT^^^^-�` <br /> FOE OFFI�E�,USE: 1601 E. Hazelton Ave. , Stockton, Calif.i) o L -ra <br /> Telephone : (209) 466-6781 �^'� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued EC 22 1977 <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 /> JOB ADDRESS/LOCATION f (� CENSUS TRACT <br /> Owner's Name ? 03E-VT i <br /> Gc c app,, �v^' Phone <br /> Address �� <br /> f F I <br /> �' City <br /> Contractor's Name License Phone <br /> _ _ I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,,� ` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINL;Q PRIVATE DOMESTIC WELL/QZ 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 <br /> Domestic/public Driven Gauge of Casing A-2 <br /> Irrigation Gravel Pack Depth of Grout Seal LkJ 4 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor W h g 2 r E 1!J 6 tj OW N&�- 04 <br /> Ill57�-{,Type of Pump SL T . FsK-MS lM' H.P. M <br /> ok ,k , 4-- h * to 0, E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: ,,r j <br /> 3W f� <br /> / / State Work Done a�� //�1.7� <br /> App f <br /> DES-TRUCTION OF WELL; 1 m <br /> p <br /> Well Diameter � �'�` oxim� De� th <br /> Describe Material and Procedure <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 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 wellin use. The above <br /> information is true to the es of m nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING MDAF L S ION <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY J l DATE -L, [-) <br /> ADDITIONAL COMMENTS: <br /> PHASE II 5ROUT INSPECTION PHASE. I/FIN INSPECTION j <br />( INSPECTION BY DATE fZ - 8- INSPECTION BY DATE - g <br /> i <br /> E H 1426 Rev. 1-743 (0 W_(10 I I Z7 <br /> 1 <br />