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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APP CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77�pSuJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3_L_27 <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 WP�f/ems' _ ._ _ CENSUS TRACT <br /> Owner's' Name - - Phone <br /> Address, 7�1 � n� f/ - T City <br /> ell <br /> Contractor's Name / License # 2f- �hone <br /> .. .gip._. <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /_� DESTRUCTION /_7 x" <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other J-7 T' <br /> DISTANCE TO NEAREST: SEPTIC TANK )`SEWER-LINES '-'PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUELIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \n <br /> Industrial Cable Tool Dia. of Well Excavation V} <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _M <br /> Cathodic Protection Rotary Type of Grout 6? SQC <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: - <br /> 1 <br /> PUMP INSTALLATION: Contractor Q� <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: / / State Work Dane _ <br /> PUMP .REPAIR: / /. State Work Done +'`3 } <br /> DES-TRUCTION OF WELL: Well Diameter � ! y Appmkimate Depth <br /> Describe ,Material and Procedure— <br /> I hereby agree to comply with all: laws and regulationsrof�rthe 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 .ori a new well, I will fu'riiish-the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the.bestlof my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR:TOG T G AND A FI ION. <br /> SIGNED TITLE �.. <br /> � . D W <br /> ' PLOT PLAN 'ON REVERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3- 2 -22 <br /> ADDITIONAL COMNENTS: <br /> -PHASE-II--GROUT INSPECTION ,-" -.- __ _-_ . _ .____. ...PHAS.E..II, /F. NAL INSPECTION . - <br /> INSPECTION BY _ DATE INSPECTION-BY- ATE <br /> E H 1426 3/76 2M <br /> Rev. 1-74 <br />