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1,6 4'o I SANJOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFI CE USE: 11601 E. Hazelton Ave. , Stockton, Calif. V <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77-l' <br /> THIS PERMIT EXPIRES 1 YEAR-FROM :DATE ISSUED ;. Date Issued <br /> t.T0 ;� - (Complete In .Triplicate) PPWA77$70Y1/ <br /> Application is hereby made to the San Joaquin Local Health District for!a pe mit to construct <br /> and/or install the work herein described. This application is made .in compliance with San Joaquin <br /> Count Ordinance No. 1862 nd the Rule and Regulations of .the San Joaquin• Local Health District. <br /> 7 L ----- fil 5• Ile r-1 t 1 s 'I <br /> JOB AD RESS/LOCATION / r i�°�` `// /•r t% <br /> ' c CE SUS TRACT Z"Z.fr-13��3$ <br /> f Owner's Name d � a04\� �9rt"!/'�'7 m) 77-7 Phone .2 <br /> - -.--0 <br /> Address <br /> 7 City �+ _ - <br />', Contractor's Name <br /> *<-.- License # ef3P oh ne 1,,. <br /> I' TYPE OF WORK (Check) : NEW WELL / / DEEPEN / =/ RECONDITION DESTRUCTION _ <br /> PUMP INSTALLATION � _ <br /> / PUMP REPAIR / / PUMP REPLACEMENT/_7 <br /> 'Other /11/ -- <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 1 Drilled Dia, of Well Casing (7� <br /> Domestic/public #<` Driven Gauge of Casing <br /> - K- Irrigation . Gravel Pack Depth of Grout Seal �y <br /> Cathodic Protection Rotary Type of Grout <br /> .Disposal f ! Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, _ 72> -�~y�., �-� a e H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> RUMP RZF7?T-R: A State Work Done <br /> D.ESjRUCTION OF WELL: Well Diameter y <br /> Approximate Depth <br /> Descrilie Material and Procedure <br /> I hereby agree .to comply withall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'coustruct.ion. Within FIFTEEN DAYS <br /> after completion of my work onta 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 o-f`my knowled nd belief.. -I -WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL,tIGPE 103 , <br /> SIGNED �S" .. ; <br /> TITLE ip�f <br /> LOT PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT .USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE /0 -.2-1 - <br /> PHASE II. GROUT INSPECTION PHASI. I/F AL INSPECTION <br /> INSPECTION BY BATE -- INSPECTUON BY DATE Q <br /> E H 1426 Rev- 1-74 <br />