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LSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICY- USE: t/ 1601 E. Hazelton Ave. , Stockton, Calif. 7--L/67 3P <br /> �G r' -, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77-3.36 ,/1. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- 7 <br /> (Complete In Triplicate) J <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 /> D � i <br /> JOB ADDRESS/LOCATION71 - of . _ u$ Y7a , -- CENSUS TRACT <br /> Owner's Name ` xptvlt,S "-" Phone 13 Y-2-?16 <br /> ,1 <br /> Address - v IL3 E dm t 's City SSC¢- <br /> -- <br /> Contractor's Name Z f License # oQ90j/3 Phone <br /> TYPE OF WORK (Check.) : -NEW WELL DEEPEN%/ RECONDITION /% DESTRUCTION /- <br /> I <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD ;,#+ CESSPOOL/SEEPAGE PIT OTHERW7.L-�� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �y <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 /> - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout &IeZ-A,�' 2 <br /> i <br /> disposal Other Other Information <br /> xGeo h sical Surface Seal Installed B <br /> PUMP INSTALLA4TION: Contractor <br /> Type of Pump C H.P. <br /> PUMP REPLACEMENT: / / State Work Done AICG� <br /> PUMP '.REPAIR: / / State' Work Done <br /> DESTRUCTION OF WELL: Well Diameter / ta Aximate Depth <br /> Des r a Mat is a 4P oced e '=` p <br /> I hereby agree to comply with all laws d regulations of the 9an,0oaquin Loc91 Health District <br /> arid.-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 GROUTING AND FINA INSPECTIO <br /> SIGNED H f TITLE f <br /> (DRAV PLOT PLAN N REVERSE SIDE <br /> FO DEPARTMENT USE ONLY j <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: [ <br /> s' P SE I PROUT INSPECTI N PHAS IIT/ NAINSPECTION <br /> INSPECTION B DATE INSPECTION BY DATEW177 V <br /> lG3 �r -70 1177 2M <br /> E H 1426 Rev. 1-74 f: r': <br />