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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FOk"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 /� �i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,77-J 4 <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 i <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 Joa uin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATIObP(© 0 � � � � oe_�--- SUS TRACT <br /> Owner's Name6&ji��6Phone <br /> A-2 <br /> Address_ .!r' /y C'. a� S City <br /> Contractor's Name License Q �s' Phone � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/�EEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR <br /> _ PUMP REPLACEMENT /� <br /> Other / / <br /> T r <br />' DISTANCE TO NEAREST: SEPTIC TANK p�rt.�_SEWER LINES IT PRIVY <br /> \. SEWAGE DISPOSAL FIELD/..CESSPOOL/SEEPAGE PIT OTHER --�� <br /> Ef� PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> y. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -+ <br /> Industrial-- - 'Cable 'Tool Dia. of We11 Excavation / C <br /> �mestic/private Drilled Dia. of Well Casing & � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack i 1 Depth of Grout Sea --- <br /> Cathodic Protection Z,--Sokary Type of Grout <br /> ` ��,�,- iy' C'G • <br /> �.. <br /> I Disposal Other Other= Information _ S7 A3�3 'Z'a P, <br /> Geophysical. S face Seal Installed By: livC <br /> PUMP--INSTALLATION: Contractor <br /> Type of Pu H.P. <br /> ! PUMP REPLACEMENT / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> IDESiRUCTION OF WELL: Well Diameter J' 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 /> land 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 Dk.I.LLERS REPORT of the well and notify them before putting the well in use.. The above <br /> informaVbq is true to€the est o my;, knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO 0 ING ANb,'A PE IO t F <br /> SIGNED - --TITLE . ;J <br /> RAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -� 79 <br /> ADDITIONAL COMMENTS: <br /> PMSEZYI ROUT INSPECTION PHASE /FIN INSPECTION <br /> ,INSPECTION BY ATE lS~ INSPECTION BY DATE <br /> 1177 _. 2M <br />