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JOAQUIN• LOCAL HEALTH DISTRI.0 - <br /> FOA;OFFICE USE: 16, Z. <br /> Hazelton Ave. , Stockton, Ca., o <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77--279 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2::L- 7 <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 Joaquix <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 'Z4AV4g Q CENSUS TRACT <br /> Owner o s Name mg EC CA scgooL '615 Phone _ YZ 3 7 111 <br /> Address . 80,-&Y 32- A44&7-�CCA City 41A&ZCCA <br /> Contractor's Name . . &C1 C1:5: ,462&2Z /NG:__ License #AO__07gy Phone cZZ?fig/q <br /> TYPE OF WORK (Check): NEW WELL A DEEPEN17 7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria,l Cable Tool Dia. of Well Excavation ZZ�! <br /> A L.r Domestic/private Drilled Dia. of Well Casing �„ <br /> Domestic/public 'Driven Gauge of Casing GA <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> } athodic Protection A_ Rotary Type of Grout dE'/VTaN/T� [� <br /> isposal Other Other Information O <br /> Geophysical Surface Seal Installed By:,--- A LOAC pej:zz <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. 2_ dy <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: J� State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter „• 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 /> 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 be <br /> st of- my a <br /> y knowled ge n d <br /> belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROMTjNG AND A NAL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> d FOR- DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE99 <br /> ADDITIONAL COMMENTS: <br /> PHAU II QROUT INSPECTION PHAS III/FXNAL INSPECTION <br /> INSPECTION BY DATE -- INSPECTION- BX 4r4DATE <br /> E H 1426 Rev. 1-74 1-74 <br />