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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : ,x(209) 466--6781 <br /> APPLICATION FOR- <br /> WELLCONSTRUCTION OR PUMP PERMI Permit No. 7 7- � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued j- ..77 <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 3,o N. � �Js �-r CENSUS TRACT <br /> Owner's Name jPhon � <br /> AddressGPCItY L <br /> Contractor's Name License # A-237-3 Phone LJ <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION j3R:­PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other 17 <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 i -� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS4 . <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 /> DisposalOther Other Information <br /> Geophysical Surface Se 1 Insta ed By: <br /> Q Q ;gig, <br /> PUMP INSTALLATION: Contractor '# <br /> 6 Type of Pump ..S H.P. Y--A- <br /> PUMP REPLACEMENT: // State Work Done <br /> F _ <br /> PUMP .REPAIR: „4} �/ � State,Work Done <br /> DESmTRUCTION OF' WELL. Well Diameter, �.. Approximate Depth <br /> ! Describe Mate=rnal and Procedure <br /> I hereby agree to comply with all laces and regulations of the San Joaquin Local Health District <br /> and the Stateof California,.pertaining to or regulatingtiwellmmconstruction. Withiri"FIFTEENA)AYS <br /> after comp ' n of my work; J <br /> oh.a�new well, I will furnish the San 'Joaquin Local Health District <br /> WELL DRI ERS. ORT of the w 11 and tify them before putting the'.well in use. - The above <br /> S' t FOR <br /> "A ion' u to e. nowledge and belief. I WILL' CALL FOA GROUT INSPECTION <br /> PRIOR 0 0 G D A ION.. . v�.. <br /> SIGNE TITLE 3 <br /> DRAW PLT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Q <br /> PHASE I1 <br /> APPLICATION ACCEPTED BY , -� - -�-- -DATE <br /> ADDITIONAL COMMENTS: '!l' <br /> ,•PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> •INSPECTION-BY7-a DATE 3 " J INSPECTION BY DATE <br /> 3/76 2M <br /> F R H 1426 Rpv. 1-74 ` <br />