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SAN JOAQUIN LOCAL HEALTH DISTRICT ��! - <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. Q <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-5�3V <br /> THIS! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g-,? <br /> ` (Complete In Triplicate) <br /> Application is h+ereby 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 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION : S Z NSUS TRACT <br /> V <br /> Owner's Name � � ._ . _ Phone <br /> Address : City <br /> t. <br /> Contractor's Name :F License # +�'��"` Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL P DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP'yREPAIR / / PUMP REPLACEMENT /-7 _ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK S-0 SEWER .LINES p -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 CONSTRUCTIQK-`SPECIFICATIONS <br /> Industrial"'- _ Cable Tool Dia, of Well Ex'c'avation /2_ 77 <br /> _XDomesti /private f Drilled Dia. of Well CTsing �'l 0 <br /> Domestic/pubfic _ F Driven. .. _.,__ Gauge of. Cas ng ��" T F <br /> � i <br /> Irrigation f Gravel Pack Depth of.<G"rout Seal <br /> C. <br /> Cathodic P:rtitectron , ' Rotary Type„of�Grout 1 , <br /> Disposal i Other Other,'Information <br /> Geophysical * Surface Seal Installed B ! <br /> PUMP' INSTALLATION:-. j x Contractor-, <br /> Type of Pump a« H.P. <br /> PUMP REPLACEMENT: / / State Work Done : <br /> PUMP '.REPAIR: ; _ / / stateµWork Done ` <br /> DESJRUC1'ION OF WELL: Well {D--kameter ” Approximate Depth j <br /> Describe Material and Procedure � I <br /> I herebyagree to comply with all laws and regulations of the Sari Joaquin Local:Health District <br /> and the State of -California.-pertaining_.to,.or regulating well "construction. ' Within FIFTEEN DAjS <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 i rue to the'best of my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO -GRO T G h4D A FI INSPE T10N. <br /> SIGNED I TITLE <br /> a <br /> -(DRAW PLOT PLAN ON REVERSE SIDE) � <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION...ACCEPTED t.BY- -DATE <br /> ADDITIONAL COMMENTS: <br /> P SE G INSPECTI N P S I I/FIN INSPECTIO <br /> INSPECTION BYDATE z "" INSPECTION BY DATE -2 <br /> k <br /> E H 1426 Rev. 1-74 I yG �l��� ? 1IZ7 �"� <br />