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USAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For, OFFICE USE: d/%'1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7777-1f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued4aza-� <br /> (Complete In Triplicate) <br /> Application is $ereby 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 Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 8 y0f CL✓z)JTX 3;0y zj-4 S CENSUS TRACT <br /> 630/ <br /> Owner's Name 1441? 4 t'E P 8#1616 Z*6hl Phone 92 :3 C <br /> Address _ 81lL t 4S 7 /7/ POSJJ PD 9,5-264- city STDG/l'TQ7✓ <br /> Contractor's Name I? 'A/ /L Y- f 1)/R L'-el License # 7jZf2 Phone I1-4s '! <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: ' SEPTIC. TANK ,SEWER .LINES + PIT..PRIVY.. _. <br /> j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /2 0'r OTHER I <br /> (•PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE f TYPE OF WELL * CONSTRUCTION SPECIFICATIONS I ; <br /> Industrial Cable Tool- Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing I <br /> Domestic/public, . Driven Gauge of Casing,f <br /> Irrigation Gravei-Pack--.-.! Depth of GroutiSealf•__`• <br /> Cathodic Protection _ X Rotary + Type of Grout` CIS 10 UT <br /> Disposal Other ' Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor / <br /> '1 Type of Pump / H.P. <br /> PUMP REPLACEMENT: / / ` State Work Done <br /> PUMP .REPAIR: <br /> /-7 State Work Done f <br /> ' t \J f l <br /> IDES•TRUCTION OF WELL: Well Diameter I kA,% pproximate Depth <br /> aand Procedure <br /> Describe-'Mit <br /> riai ' <br /> I hereby agree to comply with-ali-4i-aws-and7regulations of the San Joaquin Local Health .iatric, <br /> and the State of California pertaining to or regulating well''construction— Within FIFTEEN DAY' <br /> after completion of my work on a new well, I will furnish the San Joaquin Local,.-Health bistricl <br /> WELL DRILLERS REPORT of the weld' no[ify them before putting thefwell -in use. The,�bove <br /> information is true to the best of my\knowledge and belief. I WILL-CALL FOR A GROUT�INSPECTIOF <br /> (PRIOR TO G OUTING AND A FINAL SPECTION. ( `� <br /> SIGNED i , Ti'TLE` <br /> DRAW PLOT PLAN ON REVERSE ShBE <br /> i FOR(DEPARTMENT USE ONLY <br /> PHASE I .1 4 ' <br /> APPLICATION ACCEPTED BY DATE jjr-/D'77 <br /> , ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � DATE Z -BnY2 7 INSPECTION BY / DATE <br />