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SAN JOAQUIN LOCALEEAL H DISTRICT <br /> EOF OFFICE USE: ' 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone: (209) 466-6781 77-779 <br /> APPLICATION FOR WELL CONSTRUCTION--OR PUMP PERMIT Permit No. �� ,�}� <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued .2-J-57- 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 Joaquini <br /> County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> J09 ADDRESS/LOCATION CENSUS TRACT i <br /> Owner's Name <br /> Phone <br /> Address /( .S /2��GL City <br /> Contractor's Name �i!/�/ �rJ(�zav .�, •c� cense._ii <br /> one <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/7./. RECONDITION /� DESTRUCTION /� 1 <br /> PUMP INSTAL TION PUMP REPAIR <br /> / / P <br /> Other UMP REPLACEMENT —7 <br /> / / <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 <br />-��...: � Drilled Dia, of Well. Casing_ <br />�TyDomestic/public E Driven k Gauge of Casing <br /> Irrigation g "G"ravel-Pack • '• Depth of-Grout Seal Cathodic Protection Rotary Type of Grout <br /> Oth3;i <br /> Disposal Other Other Information <br /> Geophysical +-..�.,�.,�._�� _�.f�-- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type-of.' U , H.P. <br /> PUMP REPLACEMENT: . t 4 e <br /> State Work Done <br /> PUMP .REPAIR: <br /> F/ State Work._-Done, . <br /> DESTRUCTION OF WELL: i -F - a• "'. <br /> We11 Diameter Approximate Depth f <br /> Describe Mater-ia2:and—Pr6eedure <br /> I hereby agree to comply with all laws and re-gulation's of the San .Joaquin Local Health District <br /> and the State of California pertaining to oriregulating well "conEtruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Sail Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe 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 />'RIOR TO GRO I AND A FINAL INSPE <br /> SIGNED . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I f <br /> kPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTIW PHASE III FINAL INSPECTION <br />[NSPECTION BY DATE"- DATE ' <br /> E H 1426 RP-Lir- 1-7L - 71 � Y 1 1 7 #]u � # <br />