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MA i L/'76 f��uMW" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FG7P,;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedJAH111978 <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 Regu ation of the San Joaquin Local Health District. <br /> G �L i 4le <br /> JOB ADDRESS/LOCATION E ✓ P6,61,&2 /?o T -VZDo kAle,OF ju y Zo CENSUS TRACT <br /> Owner's Name M , , rj GOI`I:�?TPUC- 1©Q C O - Phone Z59— I ®� <br /> Address City MA h)-v e-C <br /> Contractor's Name �g 1 �gG-� �j Q.pr� License # 00613 Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 — <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 10O l SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �-1 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 AV,'Dip, M <br /> Domestic./private Drilled Dia. of Well. Casing ( " 01 b. - <br /> Domestic/public Driven Gauge of"Casing _ 162 CD pyC. _--- _ <br /> Irrigation _� Gravel Pack Depth of"Grout Seal E5C> <br /> Cathodic Protection x Rotary Type of Grout E_= --tD" I <br /> Disposal Other Other Information L,4�, >Y OAJ 1 A-:e- <br /> . Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump - T H.P. -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <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 GRO ING AN A : INSPECTION. <br /> SIGNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 17 <br /> APPLICATION ACCEPTED BY DATE <br /> j ADDITIONAL COMMENTS: <br /> PHASE n GROUT INSPECTION,. PHA II/FI INSPECTION r <br /> INSPECTION BY DATE L/" INSPECTION B DATE <br />{ F -R I L 9-i-..- 17a,�F 1 `7G f S�i t7�7f�_ 2 _ <br />