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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7]_ )Z <br /> 77-7,P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7�,7 <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 ��b /t�i�Gii ��� A✓e- CENSUS TRACT <br /> Owner's Name _ S s�"_7 , rV_,_ ��.c�r c,, Phone <br /> AddressC p '' jE' /�p�C_ city <br /> Contractor's Name ��C � /'�r�-r,2� Ll�c License j, Phone - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> 'PUMP INSTALLATION < PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK�y �SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /,00/ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEA PRIVATE DOMESTIC WELL,5—'O_' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing z/- _s .140 �i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ^ Rotary Type of Grout � _ „"tet is �<•� �,a,�"� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION Contractor /G <br /> Type of Pump _.._ , c 1 m �.-r: �. H.P. <br /> f. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San 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 new well, I will furnish-the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT he well and notify them before putting the.-well in use. The above <br /> information is t to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU FI SPE N. <br /> SIGNED TITLE <br /> !"(DRAW-PLOT PLAN ON REVERSE S IDE� W <br /> DE TMENT USE ONLY <br /> PHASE Id� <br /> _4� / %J DATE <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: <br /> PH <br /> AS9,/II ROUT INSPMION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1-.3 --)5 <br /> E H 1426 Rev. 1-74 3/76 2M <br />