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f SAN JOAQUIN LOCAL HEALTH DISTRICT �h <br /> FOR OFFICEtUSE: 1601 E. Hazelton Ave. , Stockton, Calif. f' <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /u�/- <br /> (CompleteIn 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 Joaquin <br /> County Ordinance No. 1862 and the Rules 'and Regulations of the '-San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION OZ l�jQ CENSUS TRACT <br /> i <br /> Owner's Name A�� 1 G Phone jz42:—.230- -_ <br /> Address CityL- ��' <br /> Contractor's Name i �� p.er � A.0) License ��� o, Phone $ d <br /> i TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / ./ PUMP REPLACEMENT <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PITIPRIVY <br /> `SEWAGL DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY`LINE # PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL'`'QV,/ 4 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of WellyCasing v <br /> Domestic/public Driven_) x- mow-_Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> C a th o di e—leo-t ec-t i can--- ----R��a�y ..�__---�yp2^••o f'•-U'rz�ii`C <br /> Disposal Other Other Information <br /> Geophysical Surface Seal !Installed By: <br /> i� <br /> PUMP INSTALLATION: Contractor " <br /> ' ,Type of Pump- ��� `�_c.`� � � H.P. <br /> j PUMP REPLACEMENT. - / State WorkkDone "` �, f <br /> PUMP .REPAIR: / / State Work Da e <br /> ` DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1 <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 'constructi.on. 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 <br /> PRIOR TO GROW NG AND A &NINSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID A <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> t APPLICATION ACCEPTED BY � _ - - _ DATE /p-A f]7 <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT .INSPECT PHASE I /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . -2-7-- <br /> 6/77 <br /> 6/77 . 2M <br />