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_ SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FO .OFFICE USE: ' 1601 E. Hazelton•Ave. , •Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7?- a 3 k_1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Yssued 4/-ap-77 <br /> F )y� (Complete In Triplicate) <br /> Application is 4ereby 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 /> � `{2 j E7- �o.� �-- , .. 203- oma -� <br /> JOB ADDRESS/LOCATION _ 1 rA1, LO7cE `3� ae ..-ZAS CENSUS. TRACT <br /> 64 . <br /> Owner's Name G fc <br /> r4 /UKP Phone <br /> Address City �c <br /> Contractor's Name .. _ 7y : _ License .4�, �//y Phone / 677,2 <br />'F-TY.PE;OF=WORK (.Check) : NEW _WELL �Am-DEEP-EN__/.�/�. RECOND.IT-ION /_,DESTRUCTION-/? <br /> ` PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br />[ SEWAGE `DISPOSAL FIELD CESSPOOL/SEEPAGE 'PIT OTHER 1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrialt Cable Tool Dia, of Well Excavation <br /> pomestic/private Drilled Dia. of- Well Casing T - -�- <br />�• _" �..' "-Domestic/public x Driven Gauge of Casing <br /> - Irrigation f Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other •-. .. Other Information (� <br /> k Geophysical �r " 't Surface Seal Installed By: �r <br /> 1, PUMP INSTALLATION: Contractor {� <br /> Type of Pump U 3 H.P. S- <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ <br /> PUMP :REPAIR u_. ./ -/„ State y .Work Done - <br /> : <br /> DESTRUCTION- OF-WELL: '-Well"'Diameter' Depth <br /> e . _ _Descr.ibe..Material'.and,.1'-r.acedur.0_ <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 /> k aftier 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 b e of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING A F NS I <br /> SIGNED TITLEf civ Z• <br /> ►• (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> '"PHASE I <br /> LkPPLICATION ACCEPTED BY DATE <br /> WDITIONAL COMMENTS: <br /> PHASE II OWUZ INSPECTION, PHASE I;AIFINAI.,ASPECTION <br /> NSPECTION BY DATE INSPECTION BY TE - <br />