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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1603. E. Hazelton Ave. , Stockton, Calif. -17 <br /> FOE OFFICE USE: <br /> . Telephone: (209) 4b6-6781 Permit No. 77 <br /> APPLICATION FOR WELL CONSTRUCTION OR PSP PERMIT - <br /> Date Issued / - 17 7 <br /> s. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _3.11 <br /> (Complete In Triplicate) ermit to construct <br /> Application is hereby viade to they San Joaquin Local Health District fora p with <br /> and/or .install the Work herein described. This application ofthetSan�Joaquinin pLocaleHealthSDistricn <br /> County Ordinance No. '1$62 and the Rules and Regulations <br /> i <br /> CENSUS TRACT � 1 <br /> JOB ADDRESS/LOCATION <br /> Owner's Name <br /> Address <br /> C.1 ' Cit <br /> License Phone _93�� <br /> Contractor's Name '• i <br /> TYPE OF WORK (Check) : NEW WELL ��DEEPEN /�/ RECONDITION C / DESTRUCTIONS _ <br /> PUMP INSTALLATION 1#-)f <br /> —PUMP REPAIR / / PUMP REPLACEMENT PUMP <br /> 5 . . A. <br /> .Other / / <br /> EWER LINE <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOSAL FIE LD �/--CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION .SPECTFICAT7 ONS <br /> t Industrial Cable Tool <br /> Dia. of Well Excavation <br /> Dia. of Well Casing, <br /> _ �f_ <br /> omestic/private Drilled ..,�,."o ' <br /> -Driven' - Gauge of Casing <br /> _ Domestic�pitblfc ---= - <br /> Irrigation- Gravel Pack Depth of Grout al `+� <br /> .s'-Rotary Type of Grout <br /> Cathodic Protection Other Inf°rmationIll <br /> Disposal Other <br /> Geophysical Surface Seal-I-nsta-Hedy <br /> . ,. <br /> UMP INST'AL'LATION: Contractor' - l ' H.P..-��.-- <br /> Type of Pum <br /> { PUMp REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: '/ / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> r{ Approximate Depth <br /> Des ribe M"terial and Procedure <br /> "laand' gulations ° the' San Joaquin Local Health District <br /> I hereby agree to comp.ly.GriWithin FIFTEEN and the State of Califor.,niaell °I will�furn s�►etheSantJoaquin.L cal Health District a <br /> after completion of my wo'xR;on a new w� �.; <br /> WELL,DRILLERS REPORT of thew 11—and'notify them before putting the well in use. The above <br /> infor on is true to a knowledge and,-belief. "I WILL CALL FOR A GROUT INSPECTION <br /> PRIORI OUT AND . <br /> I ECT N.® <br /> . f�,. <br /> SI RAW PL T PLAN ON RE E'RSESIDE) <br /> FOR DEPARTMENT-USE ONLY r ' <br /> PHA . DATE �QN APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P II/ N INSPECTI <br /> P SE II GROUT INSPECTION i"INSPECTION BY DATE <br /> _- ss, ,. DATE 3 '" <br /> INSPECTION BY <br /> �� ':3/76 2M <br />