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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ZZ <br /> C, n Date. Issued 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r - = <br /> (Complete In Triplicate) <br /> , <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 1e San Joaquin Localliancin comPe Health,Districtin <br /> County Ordinance No, 1862 and. the Rules and Regulations of <br /> CENSUS TRACT ' <br /> JOE ADDRESS/LOCATION pGi. ' <br /> Phone7 < <br /> Owner's Name ' <br /> city <br /> Address l �� <br /> License # ��Phone .6 .9-:)"7593 <br /> Contractor's Name <br /> DESTRUCTION � <br /> PE OF WORK (Check); NEW' WELL /DELEPEN /� RECONDITION REPLACEMENT r w <br /> k PUMPIINSTALLATION I/ MP PUREPAIR / PUMP:/ <br /> +al <br /> 06er4 %1 <br /> PTT PRIVY ,_ <br /> DISTANCE TO NEAREST: SEPTIC TALAR SEWER LINES j OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ <br /> PROPERTY LIFE - PRIVATE D(}IiSTICIWELL PUBLIC STIC L <br /> INTENDED USE TYPE OF WELL _� . CONSTRUCTION SPECIFICATIONS ,Cable-Tool Dia. of Well. Excavation <br /> Industrial Tilled Dia. of Well Casing <br /> � 6mestic/private �-- Driven <br /> Alllm` t Gauge of Casing f'L <br /> Domestic/public _.- <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation Type of Grout <br /> Cathodic Protection �L Utary s ---Others_Information <br /> -M- -� - Other <br /> Disposal _ �� <br /> { Surface Seal Installed B fJ <br /> Geophysical <br /> PUMP INSTALLATION: Contractor HX. <br /> Type of Pump <br /> State Work Done `'- <br /> PUMP REPLACMGMT: I I -- - <br /> . tate Work Done <br /> PUMP REPAIR: <br /> _- a� h s®r, <br /> 6L 0 w G L C. .�/ ApproximateDepth 6 <br /> DESTRUCTION F WE Well Diameter 6 <br /> esckibe Material and Procedure - ; <br /> arab a Tee to comely with all Taws and regulations of the <br /> construction.LoWithiienaPIBTSB�it 7($. <br /> G I h y 8 pertaining to or regulating well <br /> and the State of California pe g <br /> after completion of my 'work on a new wall, I will furnish the San Joaquin. Local Health, Dstriet a <br /> ' LL DRILLERS REPORT of. the well and notify them before putting the -well in use. The adve` <br /> WB <br /> information REPORT <br /> to the Wiest of my. knowledge and belief. I WILL CALL FOR A GROUT I SpECTIf is <br /> PRIOR TO GRO TING AND INAL INSPECTION. TITLE <br /> SIGNED ;. <br /> D W.. PLAN ON RSE SIDE <br /> FOR DEP TMSNT USE ONLY <br /> PHASEDATE <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL {OMLMTS; pHA II F AL INSPECTION`. <br /> p E I G UT INSPECTION -77 INSPECTION B DACE <br /> INSPECTION B <br /> DATEev / <br /> E 1426 Rev. 1-74 <br />