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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFOErOFFICE USE: 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone:P {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 835a� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a-,2 <br /> (Complete In .Txiplicate) <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. 1.862 and the Rules and Regulations of -the San Joaquin Local Health District. <br /> JOB ADDRESS/.LOCATION --2,L20 -W, -S�7-Rpt;z-7-. A CENSUS TRACT <br /> Owner°s Name 0Rt2Q1t,1AE � Aj %M,� Phone Cl ,7_4 '' <br /> Address' - <br /> City <br /> Contractor's.Name A10.Ac j-g- ,� .� ,r License #212227zL` Phone <br /> TYPE OF WORK (Check):.~ NEW WELL .N DEEPEN /7 RECONDITION /7 DESTRUCTION 1_7 I <br /> PUMP INSTALLATION / / PUMP REPAIR /—/,—PUMP REPLACEMENT l7 <br /> • Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK 2r1Q ` SEWER LINES .PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT'__. ; <br /> OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC-WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL - � ' CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Taos., Dia, of Well Excavation � <br /> . Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z T 77 V Z, <br /> Irrigation '- , Gravel Pack Depth of Grout Seal _ g <br /> Cathodic Pro ection Rotary Type of Grout <br /> Disposal 'Other, Other Information fi <br /> Geophysical Surface Seal. Installed By: <br /> 1� f <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /�/ State Work.DWhe <br /> I'UMt' '.REPAIR:�. 4J-- --/ =State_Wark-Done <br /> ES'TRUCTION OF WELL: Well Diameter "'4` .K Approximate Depth -.:-- <br /> Describe Material and Procedure ' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local 'Heaith District F <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AN A F4NAL INS ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED YDATE �� - 2 7 <br /> ADDITIONAL COMMENTS: ( _ -- <br /> PHASE II GROUT INS ECTION P11ASE III FI AL INSPECTION <br /> INSPECTION BY DAT Q--- --77 INSPECTION BY DATE /- <br /> 4 E H 1426 Rev. 1-74 <br />