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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR. OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 7 7-S7s`✓ <br /> f 77- SS 1P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued)7 <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for aermit to con <br /> P struct <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 /> r <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone �S1 .Y7Tff <br /> Address �'G� (c <br /> Otto 'City '. l <br /> Contractor's Name .. -"'� � -" " . - -w" _ - . - �T- n ' <br /> +.License / g 77 Phone <br /> TYPE OF WORK (Check)4: NEW WELL DEEPEN '/— <br /> RECONDITION / / #DESTRUCTION /_7PUMP INST TION iy/ PUMP REPAIR / / = PUMP REPLACEMENT /7 <br /> Other <br /> � 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY //l�.{ ///[7/� <br /> °�a Y-f0y7� SEWAGE DISP05AL <br /> SCIAI FIELD CESSPOOL/SEEPAGE PIT T OTHER <br /> ?kPROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC -WELL <br /> Z T NDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indus tri-al-`-�. --�.,. .. .0 1 <br /> Cable ToolDia-.'­of _W611 Excavation <br /> Domestic/private Drilled Dia. of Well Casing �+ <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation ? <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Disposal Dis Rotary T e of Grout <br /> p Other K-"^ '-"- Other Information <br /> Geophysical Surf ac67Se'al71IHstalled B : <br /> PUMP INSTALLATION: Contractor i-J6 <br /> Type of�Pump C, H.P. <br /> PUMP REPLACEMENT: '�`"� <br /> State Work Done <br /> - <br /> PUMP '.REPAIR: / / State Work Done <br />)ES•TRUCTION 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 <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 /> BELL DRILLERS REPORT of the well and notify them before putting. the .well in use. The above <br /> Lnformation is true to the best of- my -knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GIO&ING AND A F NAI, INSPECTION. <br />)IGNED TTTL <br /> (DRAW PLOT PLAN ON REVERSE ST E <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> , <br />►PPLICATION ACCEPTED BY DATE j� <br /> LDDITIONAL COMMENTS: <br /> PRAL,W U GROUT INSPECTION PHAS IIT/FINAL INSPECTION <br /> INSPECTION BY 2W=Len= DATE ��—fg^7 7 1NSPECTZON BY DATE G 3 8 r <br /> E H 1426P Rev. 1-74 1/77 _ 2M <br />