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F <br /> ii <br /> 1 <br /> ih SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo— ?OFFICE USE: I . Hazelton Ave. , Stockton, Calif. <br /> I� 1601 ETelephone: (209) 466-6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-,q1,4 <br /> t . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued _7 <br /> I (Complete In Triplicate) /9: = 0,7,0 _6_2' <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 Joaquin <br /> County Ordinance-.No.;.18b2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> K -o 3�S uJ nJE _ <br /> JOB ADDRESS/LOCATION 5 C u! I ' CA/ CENSUS TRACT <br /> I <br /> Owner°s Name �� ��/� �3 �� - Phone <br /> Address - c 2/ t. " G 1 V' City SJO ;Fa,jl� Vd-2G:)' <br /> Contractor's Name � f :� t1 -CO, License # Phone -SJ <br /> J TYPE OF WORK (Check): NEW WELL/� DEEPEN "' RECONDITION DESTRUCTION <br /> PUNP JINSTALLATTON F7 PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLISEEPAGE PIT OTHER <br /> PROPERTY LINE,--PRIVATE DOMESTIC WEL'Ll_ PUBLIC"DOMESTIC'WELI <br /> r .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS, <br /> :Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing N, <br /> Domestic/public Driven Gauge of -Casings + <br /> Irrigation' Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other , 4 Other:Information <br /> Geophysical I� Surf6ce Seal Installed By: <br /> IIt <br /> PUMP INSTALLATION: 'Contractor <br /> Type of.Pump H.P. <br /> f PUMP REPLA} CEMENT: L/ IState Work Done - <br /> PUMP '.REPAIR: /� State Work Done ^. <br /> PES-TRUCTION OF WELLY: Well_ Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby Agree Co 'amply with all laws and regulations of the. San Joaquin Local Health District <br /> and the State of California-pertaining to or-regulating-well`corist- uttion:_ Within FIFTEEN-'DAgS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT ofll'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 GROU IN AND AI'FIN INSPECTION. <br /> SIGNEDTITLE <br /> N DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 �h FOR D PARTMENT USE ONLY <br /> PHASE I I f <br /> APPLICATION ACCEPTED BY, / DATE / /317' 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 0. DATE INSPECTION- BY DATE 3 '„, 3.77 <br /> i E H 1426 Rev. 1-74 1-74 2M <br />