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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 PUNK' PERMIT Permit No. 77-1�[1�crJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .�c-�6 <br /> R (Complete In Triplicate) j t�fCJ- <br /> Application is Aereby made to the San Joaquin Local Health District for apermit 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 `� -AA j r. CENSUS TRACT <br /> Owner's Name Phone y <br /> / . <br /> Address _ f �� - 1 os c City ' .�n�t <br /> Contractor's Name License # Phone S/ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7. DESTRUCTION:. /-,7 ' <br /> PUMP ,INSTA LATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �( <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE `-PfIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL -CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of.Well Excavation 7 9, '• u1�0 <br /> �2 <br /> Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of G eal <br /> Cathodic Protection Rotary Type of out G <br /> Disposal Other Other In ation <br /> Geophysical cSurface Seal Insta <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L State Work Done <br /> P1NIP':REPAIR c_., %"/'-Stote"W6r 7Dorie ' <br /> DESTRUCTION OF WELL:— Well Diameter' v Approximate Depth ' ' <br /> Describe MAterial and...Procedure <br /> I hereby .agree to comply with all laws and regulations of the San Joaquin Local health Di.strict� <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 <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 TOGVVZING OD A FT NS C ON. <br /> SIGNED. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL .COMMENTS; A�+SL <br /> PHASE ROU INSPECTION IIA E /AN INSPECTION <br /> INSPECTION BYDATE 7 7 INSPECTION BY DATE �' 2 <br /> 1/.77 2M <br />