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5' w <br /> } <br /> SAN-J,OAQUIN LOCAL HEALTH DISTRICT <br /> For, OFFICE USE: 1601 E. ha-zelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77- <br /> THIS <br /> 7-THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o azef-22 I <br /> if (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 workjherein 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 -,,, q ,._CENSUS TRACT <br /> Owner's Name ,v _ Phone 951-�Z b 7 3. <br /> Address :3 j e e u city sem -tr.� - - -Contractor's nameN.C&r&,� �- _.�? „� License �� ( Phone �c�-9�3� <br /> E <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION f / DESTRUCTION /7 <br /> f PUMP INSTALLATION / / PUMP REPAIR /,Z _PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ h � <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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br />` Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface _Seal Installed By: <br />!, PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. <br /> f k <br /> PUMP REPLACEMENT: /. / State Work Done <br /> PUMP .REPAIR: / / State Work Done, C',C r..af u �• Ra bosAj k ' <br /> DESTRUCTION OF WELL: Well Diameter . -- Approximate Depth <br /> Describe Material"and Procedure <br /> i <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 i. <br /> WEL'L'DRILLERS REPORT of:!,the well and notify them before putting thewell 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 GROUTING AND A F.FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE S DE) <br /> �I <br /> FOR DEPARTMENT USE ONLY <br /> r � <br /> PHASE I A- . <br /> APPLICATION ACCEPTED BY DATE -29-22 T <br /> ADDITIONAL COMMENTS: 1. <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION 1 <br /> INSPECTION BY DATE INSPECTION BY DATE ,s=j <br /> 6��7.7 _ 2M <br />'�< � E H 142b Rev. , 7--74 <br />