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i <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO :OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued h/-C--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 /> Count Ordinance No. 1862 and the Rulee' and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION MIZ,,5 :5 H JL�iu`* /32- 11fp /Eb CENSUS TRACT <br /> Owner's Name �C�� OSC Phone <br /> Address 3o77-3 City <br /> Contractor's Name �.�✓11-0eS /�Utij l� �� - License #-2 730' Phone <br /> TYPE OF WORK (Check): NEW WELL /lam :.DEEPEN -/-7 RECONDITION /__7 DESTRUCTION /T <br /> PUMP. INSTALLATION '/ / PUMP -REPAIR /7 PUMP REPLACEMENT /7 <br /> OtherIn <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPO AL 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 /> Domesti o_at <br /> uDomespblic <br /> Driven Gauge of Casing Y41 <br /> T7 Irrigationy 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 4s <br /> Type of Pump H.P. ' <br />` PUMP REPLACEMENT: . / / State Work Done <br /> 0 PUMP .REPAIR: /� .State Work Done <br /> DESTRUCTION OF WELL: Well Diameter !' Approximate Depth k <br /> Describe Material and Procedure d <br /> 11 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> sand the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS; <br /> rafter 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 End belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TO RROJJTING AND A FINAL INSPECTION. # <br /> SIGNED jLftk 0 TITLE <br /> (DRAW PLOT, PIAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g <br /> APPLICATION ACCEPTED BY DATE ' 3 s2'9 Z'l <br /> ] ADDITIONAL COMMENTS: -- - <br /> PHASE II GROUT INSPECTION P E I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f <br /> E H 1426 Rpu- 7-76 z r 4/75 2M <br />