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." SAN JOAQVIN LDCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeft-on Ave. , Stockton, Calif. ' <br /> „-•- Q <br /> Telephone: (209) 466-6781 ' <br /> � <br /> ` C, -1 11. : i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/1 (�/ S <br /> / � /7 <br /> r 'iTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,.-7-7 17 <br /> Application is hereby made to the San (complete <br /> Triplicate) <br /> ox ae`permit�to construct <br /> 77- V147 <br /> Joaquin Local Health District f <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 j ! <br /> CENSUS TRACT <br /> Owner's Name <br /> � Phone <br /> Address � � ( � _� . .-•.. o <br /> 10 - ' ��- 1 . City ��A N I n el? �A <br /> t - r <br /> Contractor's Name • L'k /10 <br /> 1 License # I146gp Phone <br /> TYPE OF WORK- (Check) : NEW WELL/ / DEEPEN -/—/ RECONDITIONt <br /> DESTRUCTION /_7 ;PUMP INSTALLATION / PUMP REPAIR PUMP J <br /> REPLACEMENT /7 <br /> DISTANT TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ y <br /> j SEWAGE DISPOSAL ELD Q ,CESSPOOL/SEEPAGE PIT �' OTHER <br /> # PROPERTY LINE -•• PRIVATE�'TIC WELL PUBLIC DO `C-: 3 <br /> ' INTENDED ,USE TYPE OF WELL I - WZT i <br /> CONSTRUCTION SPECIFICATIONS - <br /> ► Industrial <br /> I Cable Tool'', � . <br /> ` �� � Dia, of Well Excavation , <br />"�1Tomestic/private ;Drilled, Dia. of/Wefl�,Casing f° <br /> } Domestic/public 1 Driven r <br /> Gauge of Casing , { x <br /> i Irrigation Gravel Pack Depth of Grobt Seal <br /> Cathodic Protection Rotary Type f Disposalof .Grout f <br /> l t <br /> Other Other Information ,�•, <br /> Geophysical--�-- - ._.._..-_ <br /> #-Surface Seal -Ins talled B : ' iI { <br /> PUMP INSTALLATION: Contractor <br /> Type of} Pump i/H.P,' _1 _ <br /> PUMP REPLACEMENT: State.Wolk Done <br /> �r, s <br /> PUMP .REPAIR: k ..V s t� v ` 5i;f=� �►, <br /> State Work Done ° <br />)E&TRUCTION OF WELL: Well Diameter <br /> yrA Approximate Depth <br />� � --• Describe Material and Procedure "- <br /> E heF , k <br /> ind. reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the_State-.ofj Californias.•pe.rta ni-n.g..,_to- qr/7regulat ng-we•11 'construction. Within FIFTEEN DAYS <br /> sifter completion of my work-on a new-well jI will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of_' tll e we1`I and opt fy them befofeputting the well in use. The above q <br /> informatio is true to t e b t my knowledge ,'a4d(-b.el`ief. TWILL CALL FOR A 'GROUTIINSPECTION <br />'R•IOR G INC I CT ZONI9/�i�C��c,� LGl1�/ <br /> iIGNED. TITLE <br /> :.� <br /> +(DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I ___I f ! . i FOR-DEPARTMENT USE ONLY /z--5;77 G+� <br /> _ rte,, <br /> LPPLI'CATION-_ACCERT-ED._BY_ �r - _.` DAT <br /> rp <br />,DDITIONAL COMMENTS: <br /> IAw <br /> PHASE IT GROUT INSPECTION t, ., P SE III/FIN INSPECTION J <br /> INSPECTION BY DATE.-� ;4=j �u�{ ft'i,;;;.INSPECTI N BY DATE <br /> E H 1426 'Rev. 1-74 a rZ�."Dve {P L.I s .i '41 � . .. 1/77. % j <br />