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C a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Jp-77 <br /> (Complete In Triplicate) <br /> Applicati n 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 �uTW 5711'0,6 6F Ae'�m�n' �� /nr fe sT n� CENSUS TRACT <br /> Acop.-Woov to <br /> Owner's Name t� ,,G,,1 26n4-id- Phone <br /> Address V6 /7 45- tgCI-W C �6& Z c City L00 / <br /> Contractor's Name Son License #2/6371 Phone3 <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR fi /; `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 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 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - -- <br /> PUMP .REPAIR: /tate Work Donel6[7 4� � IV <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 thewellin 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 A FINAL INSPECTION. <br /> SIGNED TITLE $cin Joaquin Puma <br /> RAW PLOT PLAN ON RE RSE SI <br /> FOR DEPARTMENT USE ONLY <br /> Lodi, Ccs Et crrAio 9.52'D <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: /77 <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />