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SAN JOAQUIN LOCAi.HEALTH DISTRICT <br /> F0T;OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-6781 <br /> a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued le-7-75- <br /> (Complete <br /> O-77S- <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 Joaquit <br /> . County Ordinance No. 1862 and the Rulee and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a ` S'.�C,�i � S S CENSUS TRACT <br /> OFT <br /> E Owner's Name Phone <br /> Address D 0 / 3 7z 0.0 City ' <br /> Contractor's Name License p hone 4 <br /> zj <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN -/7 RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR'/-7—PUMP REPLACEMENT /X7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL L CONSTRUCTION SPECIFICATIONS <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 : <br /> PUMP INSTALLATION: Contractor eGl � <br /> Type of Pum H.P. <br /> Y! ! <br /> PUMP REPLACEMENT: / State Work Done . �y /,qm - d`' ZZ/ fV <br /> . ... <br /> IVy:s <br /> PUMP.:REPAIR: / / State Work Hone <br /> DESTRUCTION OF-WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> ` I hereby agree to comply withal.l laws and regulations of the San Joaquin Local Health District <br /> and the State of California .pertaining to or,. regul.ating 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-best of my k owledg belief. I WILL CALL FOR A GROUT INSPECTION <br /> iPRIOR TO ING AND A FINAL IN <br /> SIGNED TLE <br /> (D W LOT PLAN ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> t APPLICATION ACCEPTED BY DATE <br /> .:ADDITIONAL COMMENTS: <br /> PHASE II 0 CTI`ON PHASE 11,1/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2-- <br /> ' E H 1416 � � <br /> .Rev. <br />