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n 7 JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: ( 16017E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE IT Permit No. <br /> 77��a/1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 L,Z <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 /> JOB ADDRESS/LOCATION 1094.�Sr &1 S]`Rd ZVMN reC 4 CENSUS TRACT <br /> Owner's Name l�Cla t'O "Al Phone 62.,3'-"'7 A Q <br /> Address /g` 1/6-S e AUSTIN W MAA. 7-r<,4 City 0-6 It T <br /> Contractor's Name 4E N4/)y�S , •�k>o s License 57'ZQ0S/ Phone SZ S-` H 85' <br /> _ N <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 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 Z/ O A1,4 L.C�_ <br /> Irrigation Gravel Pack Depth of Grout Seal 5.0 <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: Done <br /> '0 GD u/eL L, -To a� )/ W / T •�� <br /> D S•TRUCTION OF WELL Well Diameter ,: �...�n• rz_VI CAX-4proximate 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 GROPJING AND A FU$L INSPECTION.. <br /> SIGNED TITLE <br /> . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II/ NAL INSPECTI N <br /> INSPECTION BY DATE z 7 -77 INSPECTION BY DATE <br /> E H 1426 Revs. 'l- :. ... ✓aN "/`,, l u �.r.rs/� _ fj , . -77 6,29 - ' 1 f7.7,f . <br />