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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: g 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-� <br /> THIS PERMIT EXPIRES 1 YEAR FRO14-DATE ISSUED Date Issued -J i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> an Joaqui <br /> and/or install the work herein descrieddTRe$ulaionstofapplicaionthe Sane <br /> JoaquinpLacaleHealthwithSDistrictn <br /> County Ordinance No. 1862 and the Ru ng <br /> CENSUS TRACT . <br /> JOB ADDRESS/LOCATION 22 <br /> Phone <br /> Owner's Name <br /> City <br /> Address _ <br /> p License # _3 Phone <br /> Contractor's Name 4 <br /> TYPE OF WORK (Check) : NEW WELL/✓I DEEPEN/ / RECONDITION_ / DESTRUCTION /? <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other 177 <br /> DISTANCE TO NEAREST: SEPTIC TANK ' _�- SEWER LINES PIT PRIVY noo-c <br /> OTHER <br /> SEWAGE DISPOSAL FIELD 5a' CESSPOOL/SEEPAGE PIT IC Dnf, WELL <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation jt " <br /> Domestic/private <br /> Drilled Dia. of Well Casing tj2 S/ " <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. "- <br /> Cathodic Protection Rotary Type of Grout <br /> BP I <br /> Disposal Other - 'Other Information <br /> __ 'Geophysical­ Surface Seal Installed B <br /> -. f r <br /> PUMP INSTALLATION: Contractor ' <br /> H. <br /> Type of Pump . <br /> PUMP REPLACEMENT: / State Work Done/ s <br /> PUMP .REPAIR: / / State Work Done <br /> --�" � - � <br /> DESTRUCTION OF WELL: We1, .Diameter t Approximate Depth -- <br /> Describe Material., and Procedure <br /> .� r <br /> I hereby agree to comply with. all laws and .regulations of-.the San Joaquin Local Health District <br /> ructian. Within FIFTEEN DAYS <br /> and the State of California pertaining to or regulating well "const <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 /> inform tion is true t t of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOS._ OUTING AND F E ION• TITLE <br /> ! SIGNE1 <br /> DRAW PIs T PLAN -ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 4 P - DATE, / <br /> APPLICATION ACCEPTED BY �/ ``N <br /> ADDITIONAL COMMENTS: �"i -W �Gf�' PHA _ I.I- ,.N. INSPECTION <br /> i PHA I ROU INSPECT - DATE <br /> INSPECTION} i <br /> DATE INSPECTION BY <br /> 7` - 3/76 2M - <br /> V x 1L2A 1Rev. 1--74r,�P�/ �q7f� .rr .. . --1 <br />