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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �1 % Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- .5i7 �9 <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .+ 232 ,3 4.1, tdrd �, CENSUS TRACT <br /> Owner's Name 6 --7,0 1V T PE ,- o Phone 366 a <br /> Address -S City n1 <br /> Contractor's Name 12� , ' D �/ --___ License #,z2 / ?Phone 3 -' 71` <br /> TYPE OF WORK (Check)-,._,.._NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> MP <br /> -- PUINSTALLATION / / PUMP REPAIR "/ / PUMP REPLACEMENT ) <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 '`,.k i ' CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable. Tool Dia.-af Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic./.publics f Driven Gauge of Casing } <br /> Irrigati�'ort ! Gravel Pack Depth of Grout Seal La <br /> r Cathodic Protection I Rotary Type of Grout <br /> Disposal 1 Other; Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> w ! � Type of Pump ; H.P. <br /> PUMP REPLACEMENT• State Work done /�I!0V6 <br /> •' - <br /> PUMP 'REPAIR: �/// State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter fkl Approximate Depth <br /> Describe Maternal and Procedure <br /> I hereby agree to comply with all lawsl"and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining-oto or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a newwell, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and nA ify 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 GR TING AND a FINAL INSPECTION. <br /> SIGNED i TITLE ,;. <br /> (DRAW PLOT PLAN ON REVERSE SIDEO�f� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: A / <br /> PHASE II,GROUT.-INSPECTION L/ PHA S. III[y;TNAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> jv I- <br /> 77, 2M <br /> E H 1426 Rev. 1-74 .. <br />