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FOE OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT C - <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r =, <br /> Telephone : (209) 466-6781 r��" / <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perm�"No! 77_1. <br /> s. `— `—� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> k 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 7oaquin <br /> I County Ordinance No, 18,62 and the. Rules and Regulations of the`-San Joaquin Local Health. Dis;trict. <br /> JOB ADDRESS/LOCATION <br /> P+�,✓ ®-� L�ta,vr' .P �c�Y; �jp 2�r,��� <br /> i CENSUS TRACT <br /> Owner's Name <br /> Z <br /> -•a Phone <br /> Address Z 3 <br /> City•30.14 ..u�• <br /> Contractor's Name (Division of Son 1oaGuen au,a,�u, co.) <br /> If License #.j/[378 Phone <br /> YPE-`OF WORK-(Check) : ' IVEW DEEPEN _ <br /> RECONDITION / 1i` DESTRUCTIQN <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES. PIT PRIVY <br /> SEWAGE DISPQSAL` FIELD �"" CESSPOOL/_S PITOTHER # <br /> PROPERTY LINE -- PRIVATE bO�MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USES <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia, of Well Excavation <br /> Domestic/private Drilled - <br /> Ddmestic Dia. -of Well Casing <br /> /Pblic Driven Gauge of Casing , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other , Other Information <br /> Geophysical �y <br /> Surface Seal Installed B : t' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / IG/ State Work Done <br /> Ip. <br /> �6 .I <br /> PUMP .REPAIR: - �Y -v.0 Cao/",U v a_j <br /> /� fl / 1 �L�O <br /> State Work Done -� S <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of ,the San Joaquin- Local Health Distrib t <br /> and the State of California pertaining to or regul <br /> after completion of my ating well construction, Within FIFTEEN DAYS <br /> work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of tte 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 CLL ORA OUT NSPECTION <br />'RIOR TO GROU ING FZlNAL NSP CT <br /> iIGNED FTI <br /> Gfe (Division of San loaquin-Sulphur Co.)11i <br /> �M W PLOT PLAN ON REVERSETLE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br />,DDITIONAL COMMENTS: IM DATE <br /> PHASE II GROUT INSPECTION { <br /> NSPECTION BY IN DATE PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE <br /> E H 1426 Rev. - 1-74 "r' <br /> u177 _ 2m <br />