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SAN JOAQUIN LOCAL,,HEALTH DISTRICT s, <br /> FOFjOFFICE USE: /1�1601 E. Hazelton Ave. ,S tockton, Calif. <br /> Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 716�G� <br /> 75-177 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-5-,Zr <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Realth 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 _ {� 3s. A�tR._09-4,6 CENSUS TRACT <br /> Owner's Name �yc�., _ _ Phone (93r 70 7/ ' <br /> Address Q 9 Q 3 2 City <br /> RContractor's Name ..r �,. w License ��, Phone <br /> TYPE OF WORK (Check): NEW WEft-M- '""'DEEPEN / -/�� RECONA TI(#N 1 - DESTRUCTION f7-- <br /> .PUMP INSTALLATION / / PUMP REPAIR / ;'/ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK/®Ql- ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (A <br /> PROPERTY LINE PkIVATE DOMESTIC WELL% PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well`Excavation,'Z1' }`p ►� <br /> Domestic/private Drilled Dia. of Well Casing - .w'" +� € <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sear O 4 <br /> Cathodic Protection '. Rotary- —Type-'of Grout <br /> 9 Disposal # Other Other Information'.)� <br /> f Geophysical f. . 'Surface Seal Installed By: _ <br /> PUMP INSTALLATION: <br /> Contractor <br /> Typet of Pump ��. �. ,. s H.P. �rY. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P.UMP_'REP.AIR:: <br /> PES•TRUCTION OF WELL: Well Diameter T Approximate Depth j <br /> Describe Material and Procedure/ 1 <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'ox 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. L.__� �L <br /> SIGNED ,� _� - TITLES , - ° <br /> (DRAW PLOT PLAN ON REVERSE SIDE) V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> APPLICATION ACCEPTED BY ' ATS " 7 <br /> ADDITIONAL COMMENTS: <br /> II GR T INSPECTION P I NAL INSPECTION <br /> INSPECTION BY t. K,a DAT 1INSPECTI N B DATE - <br /> E H 1426 Rev. 1-74 ' 1-74 2M <br />