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` - SAN JOAQUIN LOCAL HEALTH-!DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-4SS_l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin,; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l G 7 Z �, CENSUS TRACT <br /> Owner's Name tA Ad Phone3�.. FjS�f i <br /> Address { <br /> it City 1 <br /> Contractor's Name License 11 Phone - f <br /> TYPE"'OFTWORK (Check),: NEW'WELL - - -DEEN / / RECONDITION /_7 DESTRUCTION /7 ~ , - <br /> PE <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 1 , <br /> Industrial _ Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public > 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 Surface Seal Installed B .,� j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done r <br /> PUNU'_REPAIR- ter_ / _/ State.�Work,.Done, __ r <br /> DE,j RUCTION OF WELL: Well Diameter x 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, z 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 es of y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TQ _ T G A FI AL S ON.° <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) ci <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 'L- E DATE �3-7� <br /> ADDITIONAL COMMENTS: _ <br /> P SE GRO INSPECTIO :PHASE TTI FINAL INSPECTION <br /> INSPECTION BY U.DATE - INSPECTION BY DATE I - 7 -7 `1 <br /> 1/77 2M <br />