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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F03F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 2.css ) <br /> Telephone:p (2.0.9) 466-6781 <br /> -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.I 7-44 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10 :2 -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. 1862 and the Rules and tions of- the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C 0� ��c0.los V t(. C '(/i CENSUS TRACT <br /> Owner's Name o� �$C CepPhone <br /> Address City E'S".j <br /> // � 01 e) <br /> Contractor's Name SJt�3G1/A D� r�ST U�►��p License # )2A I(oS Phone <br /> oZ75HiP.0•(3oX3 ' Ccn+Lho °,p-Soua- 96/.-76 ~ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / _ <br /> / DESTRUCTION / _ <br /> PUMP INSTALLATION�_ -PUMP REPAIR / / PUMP REPLACEMENT <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 /> mestic/private Drilled Dia. of Well Casing Z '' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ethic <br /> Disposal _� Other 1ey�VSe Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �c�gGVl � SSS c. o U <br /> Type of Pump � ��r�tevs lam„ i �� H.P. 7'v <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 <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 GRO IN A FINAL INSPECTION. <br /> ��— <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �C � 7 ? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FI N,L INSPECTION <br /> INSPECTION BY DATE /-#1y '1 INSPEC ION BY t�-e DATE ev_ 3_ <br /> E142i04� 7 <br /> Re-v. . 1-74 <br />