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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.,, Stockton, Calif. <br /> Telephone: .(209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 2,- /0 Z <br /> THIS PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED Date Issued,g- <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 / 5 A N 1-2'a 9 4f A M1212 R R CENSUS TRACT <br /> Owner's Name MO N A RC&A/0ztiA-9 _ _�....— Phone S 3 7.r `79 e; - <br /> Address . . 3 5 NIy /W 0R e- City <br /> 4 <br /> Contractor's Name &S& -71V fit.. HAPER _- -----�— License # 97.2_3o Phone 4177 f$S } <br /> TYPE OF WORK (Check) : NEW WELL Z DEEP /,_7 RECONDITION /_7 DESTRUCTION /_ j <br /> PUMP INSTALLATION jyrPUMP REPAIR / / PUMP REPLACEMENT /_7 A. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKpa*r!�SbFjSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F1ELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5-0 <br /> _ <br /> Other - Rotary Type of Grout ,,, „ -' <br /> Other Other Information <br />� PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State'Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 4STRUCTION OF WELL: Well Diameter <br /> t �EApproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the 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 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 is true to the best of my knowledge and belief. <br /> SIGNED /UPS-aLt- /c< �--. z �ITLE <br /> �T ,� <br /> ^' (DRAW P 0 PLAN ON REVERSE SIDE <br /> -FOR DEPARTMENT USE ONLY <br /> f PHASE I - <br /> APPLICATION ACCEPTED BY DATEg _,7 <br /> ADDITIONAL COMMENTS: <br /> PHAS II ROUT INSPECT ON PHAS TII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3�3 <br /> CALL FOR ROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP CTION. e <br /> E H 1426 7/72 IM <br />