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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 77-78�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 81,27 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> SFaci�-ds <br /> JOB ADDRESS/LOCATION S.Jo oT lu-sfCr,,r �AAL <br /> ��.► CENSUS TRACT <br /> Owner's Name W u,,Pf2 j C k•'t -1ZuS r A4 i Ck6 &A 0 a e U A.)e- s.A&>l Phone <br /> Address //U tc_ City <br /> Contractor's Name Son.Joe^:^.'n 7't-1p CO. License d44_?78 PhoneJt0� 71 <br /> 1—Mill StAphlip Ce <br /> C i <br /> TYPE OF WORK (Check): NEW i%tLL // DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION /t-PUMP REPAIR/ / 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 .57.✓ Z37&' q Lt tj su C� U <br /> Type of Pump ,e_ as 73 .c.- H.P 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 GROUTING AND A FINAL INSPECTION <br /> SIGNED TITLE San Joagt,;n PLJ,12 Co. <br /> RAW PLOT PLAN `ON RE RSE SIDE <br /> waion of S L6quin Sul'Sur Co,) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lai€, Canra SLC <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE l <br /> E H 1426 Rev. I-74 <br /> 3/76 2M <br />