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t 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 PUMP PERMIT Permit No. Amiip <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued77 <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 - ��"^"'� f i'�— CENSUS TRACT <br /> Owner's Name MINA Grz— Phone 0-3:2 93 <br /> r <br /> Address city <br /> y <br /> Contractor's Name J" I IZ7 1�.1°'� ti/ /� I)A 1,/.X-bicense # Phone <br /> L <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN '/ / RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /r <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LAVES PIT PRIVY <br /> SEWAGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL w <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W. <br /> Industrial 7 5 Cable Tool Dia. of Well Excavation Ul <br /> Domestic/private 1 Drilled Dia. of'Well Casing <br /> Domestic/publick 1 Driven Gauge of Casing _ <br /> Irrigations 1 Gravel Pack Depth of Grout Seal <br /> Cat_hodicProtecton t Rotary Type of Grout <br /> Dispo al i Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ej k7m H.P. <br /> PUMP REPLACEMENT: . / / 'State Work'Done <br /> PUMP .REPAIR: / ./ :zState Work Done <br /> --- <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material arid"Procedure <br /> Y hereby agree to comply with all laws and regulations of the Sari 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"knew well, i will 4urnish the San Joaquin Local Health District a <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 TO GRO T G D_A 1N INSPECTION. <br /> TITLE 1 - <br /> SIGNED - 1.- �n*;,F, <br /> RAW <br /> PLOT' PLAN 'ON RE FRSE SIDE)- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DA'TE� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPECTION PS I/FIN SPECTI N <br /> h INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. '1-74 <br />