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SAN JOAQUIN LOCAL-.HEAI;TH 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued -5-77 <br /> ' p (Complete In Triplicate) <br /> Application is hereby &de to the San Joaquin Local. flealth District far a permit to.-Construct <br /> and/or instar, the work herein 'described: This application is made .in- compliance with San Joaquin <br /> County Ordinance No, 18I62 .and the Rules and Regulations of the .-San -Joaquin Local' Health District. <br /> JOB ADDRESS/LOCATION J 3 c�� S' <br /> GENSUS ,TRACT <br /> ►' Owner's Name <br /> Phone — d <br /> 2 Z� <br /> Address ' <br /> city , ., <br /> Contractor's Name /VOA,- � 7 <br /> License # ' Phone . <br /> TYPE OF WORK (Check}: NEW WELL 'V DEEPEN j-7 RECONDITION <br /> N f7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR -/-7—Pump EREPLACIOEMENT <br /> Other <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 �r <br /> INTENDED USE ryl TYpE OF WELL CONSTRUCTION SPECIFICATIONS `m <br /> Industrial I Cable Tool Dia. of Well Excavation �I <br /> Domestic/private ; j Drilled _ <br /> Dia of Well Casing; �. <br />�Da��sic-�publi�c . .. _ <br /> Gauge of Casing � . , <br /> F irrigation _ Gravel Pack Depth of Grout Seal �'��'�'""`"""' <br /> athodic Pr_otecti_ on Rotary T e of Grout6<6 <br /> Disposal I Other YP <br /> Geophysical 0 her Information <br /> S rface Seal Installed 'B : „ a <br /> PUMP -INSTALLATION: Contractor <br /> Type .of Pu 4 . <br /> . � mP � R.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /Mi7 State Work Done .� <br /> DESTRUCTION OF WELL Well Diameter '� <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to complyilwith all laws and dregulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after •coaepletion of my work on a new well, I will furnish th`e 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—t6—best of- m knowledge and belief. I WILL CALL FOR A ZROUT INSPECTION <br /> RK2LM_qROpTT&C AND A FINAL I SPE <br /> SIGNED Ah -�" TITLE <br /> ...,.� <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE I • !' FOR DEPARTMENT USE ONLY <br /> iJ <br /> APPLICATTC?N ACCEPTED BY .I 46� DATE g'lq 77 <br /> ADDITIONAL COMMENTS: l� <br /> P 0 INSPECTI N P III IN INSPECTION,, i <br /> INSPECTION.BY ,DATE <br /> INSPECTION BY <br /> C .,y c DATE <br /> E H 1426 Rev. 1--74 <br />