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SAN JOAQUIN LOCAL 'HEALTH DISTRICT�� <br /> FOR.OFFE USE: 1601 E. Hazelton- Ave. , Stockton Calif. ' <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL. -CONSTRUCTION OR PUMP PERMIT Permit No. L2 77P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -11-77 <br /> (Complete In Triplicate) f Ell f CPO__09 <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 r1r,6269 CENSUS.TRACT <br /> s <br /> Owners Name Phone <br /> Address / y r City 4 a <br /> Contractor's Name ' License # jg37L Phone .6y 6 (a <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /-7 <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 i ! <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC-.;bOMESTIC WEL ;` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO S .I <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 j <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B' : <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pumpb oho NH.P. Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR; r <br /> State Work Done W <br /> DESTRUCTION OF WELL: Well Diameter 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-1 <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, 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- mye 'wled e• and be ief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AYNP A FIN ,ION. <br /> SIGNE , <br /> ,� TLE rb-i <br /> ( W 0 PL ON RE RSE SIDE) <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �', DATE t26,1_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II kOUT INSPECTION PHASE TTI/FINAL INSPECTIODT <br /> INSPECTION BY DATE INSPECTION BY DATE rZ_2 151A77 <br /> E H 1426 RP-7- 1-7L 1177 _ 2M <br />