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y SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.OFFICE USE• /11601 E. Hazelton Ave. , .Stockton, Calif. <br /> I <br /> Telephone: (209) 466-6 '81 <br /> APPLICATION• FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued 3—//"77 <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. 186,2 and the Rules and Regulations of the San Jo quirt Local Health District. <br /> JOB ADDRESS/OCATION j� f CENSUS TRACT <br /> x Xy <br /> Owner's Name �,�/.aN f� j� .Sa k. .�c .2u `/ Phone <br /> Address .� {. l„. � c,��.�H E` ` --- ---- Cfty S ... . <br /> T_^ dC . Iii✓ <br /> Contractor's Name �. License It/Zip 6 •y" Phone g3gp Q S <br /> 'a <br /> TYPE OF WORK (Cheek) : NEW WELL / / DEEPEN V. RECONDITION /_7 DESTRUCTION <br /> i <br /> PUMP INSTALLATION. /_,/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> t Other <br /> ISTANCE TO NEAREST: ASEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (� <br /> ;PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS d` <br /> Industrial '' I Cable Tool Dia. of Well Excavation <br /> Domestic/private .l Drilled Dia, of Well Casing T/ " <br /> Domestic/public. j Driven Gauge of Casing <br /> Irrigation E Gravel Pack Depth of Grout Seal <br /> Cathodic -Protection Rotary Type of Grout <br /> Disposal , Other Other Information _ <br /> Geophysical Surface Seal Installed <br /> I� Tac kfa,v <br /> PUMP INSTL Contractor <br /> ' <br /> ALATIO s N: - Cont <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /, / State Work Done T - <br /> PUMP -.REPAIR: / / State Work Done <br /> � F <br /> ,DESTRUCTION OF WELD: Well Diameter Approximate Depth <br /> 3 Describe Material and Procedure <br /> f .__.. <br /> lI hereby agree i.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 /> t after completion of my work on a new well, I will furnish the San Joaquin Local. Health District a <br /> WELL DRILLERS REPORT ofl� 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 GRO <br /> JJING ANk A N SPECTION. — _ - <br />' SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> fI F PART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACE V2 G/ DT DATE '/(� 7 <br /> ; ADDITIONAL COMMENTS: <br /> PHASEtIIGROUT INSPECTION PHASE III/FINAL INSPECTION M7 <br /> INSPECTION BX F DATE INSPECTION BY DATE 3-.x- <br /> 4� 111Z7 2M <br /> F. H 7626 RPl7- i_76 -f <br />