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!w 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. 777�1, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �? , 77 <br /> (Complete In Triplicate) <br /> Application isih'ereb1 0�5 y 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 ,s j <br /> CENSUS TRACT <br /> Owner's Name 971 // IPhone ' <br /> Address <br /> City ��cLP.:rir <br />.Cpntractor's Name <br /> - Licenser331,/y1- Phone / <br /> 1 � 'ZX , <br /> TYPE OF WORK (Check) : . NEW WELL / DEEPEN / / RECONDITION /-7 DESTRUCTION /7 # <br /> PUMP INSTALIATION / / PUMP REPAIR/ / PUMP REPLACEMENT ./_7 <br /> Other <br /> D;STANCE TO NEAREST: SEPTIC TANK SB SEWER LINES —So Af PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD --� CESS OL/SEEPAGE PIT OTHER y <br /> PROPERTY LINE/bGPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia. of Well Excavation `o, <br /> Domestic/private Drilled Dia, of Well Casing r <br /> .Domestic/public Driven- Gauge-of-Cab ing f2 AF L4&jr " <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary P Type of Grout c <br /> og <br /> Disposal Other Other Information` - <br /> Geophysical Surface Seal Installed By: <br /> _E16-- .2/,4, <br /> S INSTALLATION: Contractor �l 'T 4 U� � � 0 �C 0 �1 ^j 'S (y P,(�y7 <br /> PU <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Fi. .REPAIR: / / State Work-Done-" <br /> DE�TRUC_TION OF WELL: Well Diameter r Approximate 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 •'con-s.truction.-.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 be t a my �wledge and belief. - I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO AND FINAL N E 'w <br /> SIGNED TITLE E <br /> RAW PLOT PLAN ON REVERSE SIDE) } <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY D <br /> APPLICATION ACCEPTED I DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT 7NSPE.CTION- PHAS SII./FIN INSPECTION <br /> INSPECTION BY /` TE7 _ -N5P_8GT,0-9 BY DATE-72---2-72 <br />