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JOAQUIN LOCAL HEALTH DISTRICT ` <br /> F01 f�FFCE U _`SE: 150 . Hazelton Ave. , Stockton, Cat '" <br /> JTele hone: ' <br /> p (209) 4b6-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /O-l�-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 Joaquiz <br /> County Ordinance No. 1862 and the .Rules and Regulations of the San Joaquin Local. Health District. <br /> Nb6.4N L�1/ G/�,T T'o G�u'a�ej-1 Snwf'fI a.,r 4�isK -J,•, <br /> JOB ADDRESS/LOCATION <br /> LENS SST Gfi ft <br /> Owner's Name <br /> _ Phone <br /> Address <br /> City Geo/ <br /> San Joaquin Pump Coo <br /> Contractor's Name (Division of San Joaquin sit €u; Coo License # Phone Cf <br /> 711 N. Sacramn�at� �. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN . RECONDITION / / DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION / UMP REPAIR /-/-PUMP REPLACEMENT /_7 <br /> Other 1/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY. LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing s <br /> Domestic/public . Driven Gauge of Casing ` . X i <br /> Irrigation Gravel Pack b6pth of Grout. Seal <br /> Cathodic Protection 3 Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ` Contractor t/i /� <br /> Type of Pump H.P. { <br /> PUMP REPLACEMENT: <br /> State Work ,Done <br /> PUMP .REPAIR: T <br /> / / State Work Done <br /> DES"TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Descri. a Material and Procedure <br /> I hereby agree to comply withzall 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 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 z <br /> PRIOR TO GROUTING AND A SPECTIO . <br /> SIGNED an oac�urn ump Co. <br /> TITLE (Division of Sal,Joaquin Sulphur Co. <br /> �1��D �WP �MA�ON REVERSE SIDE) N. Saicrts:t enta St. r <br /> FOR DEPARTMENT USE ONLY LOW, all arnia 1. D <br /> PHASE I <br /> APPLICATION ACCEPTED BY l <br /> ADDITIONAL COMMENTS: DATE <br /> j <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECT <br /> TON BY DATE - Z-3 '7 <br /> I <br /> E H 1426 0/77 _ 2M <br />