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FOR., JOAQUIN LOCAL HEALTH DISTRICT <br /> ;OFFICE USE: 1601 E.. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79 <br /> 1.3 .1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �_G'S�[ 3-3-,W1 .' r Date Issued <br /> p�a6" .®!L (Complete In. Triplicate) -~�--� <br /> App - iereby made' 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 Jroaquin, <br /> Count Ordinance No. <br /> County 1 f� and he Rules and Re ulations of the Saar Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , <br /> �7 r ' �`•__ G'�!/c'RlEr� .. CENSUS TRACT D -32o-S! <br /> Owner's Name <br /> Phone <br /> Address SOC? �l/f sem•. d <br /> City - 71G(. <br /> Contractor's Name <br /> License - f673? Ph one w <br /> S <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN ' RECONDITIONy - <br /> t <br /> ...-.....--'''` PUMP INS ALLATION L� /? DESTRUCTION. /7-7- 1.. , <br /> Other /j f I PUMP REPAIR 'l , PUr� REPLACEMENT <br /> Ff7 h <br /> . <br /> DISTANCE TO NEAREST:. SEPfiIC TANK <br /> d' SNE R�,INES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /410 CESSPOOL/SEEP GE PIT <br /> OTHER <br /> INTENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLZ157 PUBLIC DOMESTIC WELL <br /> TYPE OF WELL <br /> Industrial ! CONSTRUCTION SPECIFICATIONS <br /> Domestic . Cable Tool Dia. of Well Excavation <br /> /Private DrilledDia.` of Well Casin <br /> g Iv <br /> °Domestic/Pciblic :� Driven <br /> Irrigation Gauge of Casing , <br /> Gravel Pack Depth of Grout Seal. � <br /> Cathodic Protection Rotary Type of Grout 9S ,Ar/ '�ca{;/D�C7 <br />-Disposal r � <br /> Other Other Information, <br /> . <br />-Geophysical --�------ <br /> •-.--.Surface Seal Installed B <br /> 3x <br />'UMP INSTALLATION: Contractor <br /> t Type of Pump - <br /> - H.P. . <br />'UMP 'REPLACEMENT: /_/ State Work Done 4 <br />'UMP iREPAxR. El .State Work Done t <br /> ,1 <br /> ESTRUCTION OF WELL: Well Diameter ; <br /> J TApproximate Depth'. <br /> Describe Material and Procedure_ <br /> r <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local HealtH District t <br /> nd the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> fter completion of my, work on a new well, I will furnish the San ,Joaquin Local HealthfDistricta <br /> ELL DRILLERS REPORT of the well and notify thein before putting..the..well. in use.... The above <br />❑formation is true to the-best of my.-knowledge and belief. <br /> LIOR TO G NG INS I WILL CALL FOR A GROUT INSPECTION <br /> FI ION. `��, <br /> EGNED TITLE yrs` <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1ASE I . FOR DEP MENT USE ONLY t <br />?P IL CATION ACCEPTED BY f% f <br />)DITIONAL COMMENTS: DATE dl <br /> PHASE II GROUT INSPECTION <br /> fSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTI <br /> /D/.a 4 5i 1rW Ct ,vnc DATE <br /> E H 1426 Rev. .1/-74 a <br />