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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOROFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. ''"' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 77- 3.Ar,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date -Issued -7� <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Ru es and Regulations of the San Joaquin Local Health District. <br /> ��1 0�a . /2W fsz <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's`Name Phone - <br /> s i <br /> Address ' lk <br /> City : Sc. __� <br /> Contractor's Name d6�Syvo ° <br /> �....�� . License #14IL2?y .Phone <br /> TYPE OF WORK (Check) : NEW WELL / (r/ DEEPEN':/ :/I! RECONDITION /_-7 DESTRUCTION /7 <br /> rPi1MP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> E. <br /> DISTANCE TO"NEAREST:: S.EPTIC TANKSEWER 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 _Casin [Lig <br />= -= Aomes 'ic/�,utrlYc:w'"= -'�-?= �7rven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Cathodic Protection Rotary Type of Grout <br /> ilisposalxaf Other Other Information !! <br /> Geophysical! Surface Seal Installed"B S <br /> PUMP INSTALLATION:{ .Contractor--mm <br /> Type of Pump <br /> 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 /> 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 .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 GROUT G D A INSPECTION. <br /> SIGNED TITLE �J L41 a/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> DEPARTMVAT USE ONLY <br /> PHASE I <br /> APPLICATION OMMEP B �Ig LI fvo DATE <br /> ADDITIONAL COMMENTS; ' <br /> PHASE JiA GROUT' INSPECTION PHAS �IN�DA�TE <br /> IO <br /> INSPECTION BY DATE INSPECTION BY <br /> E H. 1426 Rev. 1-74 _ 1/77 �Hr <br />