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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= Lf�;/4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <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 -Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION Ll,-XAVOO CENSUS TRACT <br /> Owner's Name AI Phone R 919- <br /> Address City Fgr,4zG�. „. ...,. <br /> Contractor's Name e / G C License # <br /> V qLPhanea32MI2 <br /> - --.. <br /> TYPE OF'WORK (Check): NEW WELL DEEPEN -/-7 RECONDITION /-7 DESTRUCTION f7 <br /> j, PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> s ; SEWAGE DISPOSAL FIELD 195, / ,-GESSPOOL/SEEPAGE PIT OTHER <br /> � f PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL '' <br /> INTENDED USETYPE OF WELL , ' '. CONSTRUCTION SPECIFICATIONS <br /> Industrial. _', Cable Tool Dia. of Well Excavation - i <br /> - ��Domestic �rivate Drilled Dia. of Well Casing _ <br /> - rct c/public - l; �.✓ <br /> Domes � /_p °-; Drive -°Gauge`"of�Casi:t—� Ur- /-?�77 '"` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionI,-",Rotary Type of Grout' p17 <br /> Disposal . , Other Other Information ^^ <br /> Geophysical Surface Seal Installed By: t <br /> UMP INSTALLATION: ° Contractor <br /> Type of Pump H;P. - ` <br /> PUMP REPLACEMENT: ki <br /> State Work Done <br /> P{�:REPAIR: /� State Wvrk Done _ <br /> ESSTRUCTION OF WELL: Well Diameter / // � �� Approximate Depth 409-10nd"P'Pl <br /> Describe Mater arocedure .]14 .,_.14 ga z, .,;,, <br /> VP <br /> Lip. IA-A <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 <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 GROU7gNP AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE `"�� <br /> RPITIONAL COMMENTS: <br /> _WNE, II OU SPECTIO PHA I FINAL INSPECTIO <br /> fNSPECTION BY - t- DATE INSPECTION BY� / DATE 42 &1-177 <br /> E H' 1426 <br /> 1-74 2M <br />