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SAN JOAQUIN LOCAL HEALTH DISTRICT */ <br /> FOR OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 - ,:5� /7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 - 7,;' <br /> (Complete In Triplicate) 0 ?p „c)L <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 Joaqui <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f JOB ADDRESS/LOCATION� `� - � L .- G SUS TRACT <br /> j Owner's Name jonee buaa Phone 5a 11- 4442 <br /> Address + City .. 2r_ACOA <br /> Contractor's Name <br /> 40 License # 7yjp Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /�/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/-/ PUMPkREPLACEMENT / <br /> Other / / <br /> DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES PIT PRIVY <br /> _.SEWAGE-DISRO A�--�I L -�--��CES"�POOL/SEP�P E SPIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ;> r CONSTRUCTION;.SPECIFICATIONS <br /> Industrial. Cable Tool Dia, of Well Excavation „ <br /> Domestic/private ,Drilled Dia. of Well Casing <br /> Domestic _. `'''`'� <br /> /public Driven,'• ; '� Gauge of Casing <br /> Irrigation ..;GraveJ_Pack - �, Depth of Grout Seal - <br /> Cathodic Protection Itotar'} - Type of Grout ,. <br /> Disposal <br /> j'Other Other Information <br /> Geophysical r ' Surface Seal Installed By: <br /> l � E <br /> { PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> R <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ` State Work Done <br /> i <br /> DESTRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree tb complyh-a17laws and regulations of the San Joaquin Local Health District <br /> . and the State of California pertainAg to or regulating well -construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish 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 FORA ROUT INSPECTION <br /> PRIOR TO GROUTIN AND A FI , SPECTION. <br /> SIGNED TITLE f <br /> j (DRAW PLOT PLAN .ON REVERSE SIDE); <br /> FOR DEPARTMENT USE ONLY <br /> lPHASE I <br /> APPLICATION ACCEPTED BY a DATE ,-7? <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASES I/FIN INSPECTION <br /> INSPECTION BYAI DATE INSPECTION BY ! '. �`GDATE �. <br /> E H 1426 Rev. 1-74 ' 1/77 2M <br />