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n ,1. <br /> . !C-*, /SAN JOAQI3XN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-- *4d <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin -Local Health Diat ict 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. i <br /> .TOB ADDRESS/LOCATION.. y. /C J) CENSUS TRACT _ <br /> owner P s Name ±�l L 0 0 ! '� / /= __ Phone .2.3 G <br /> i - City /f`AM/T - <br /> Address' / <br /> Contractor s Name J � <br /> Q License # GGA Phone Z <br /> TYPE OF WORK (Check). NEW WELL / _ ION /� DESTRUCTION fT <br /> PUMP f TION PtiA�-REPAIR — PUMP REPLACEME1�iT . <br /> Other 7Nh <br /> -DISTANCE TO NEAREST: SEPTIC TANK PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> `f <br /> omesxinl-mb1ic .= :�_ �Driy�n Gauge of as ilg <br /> Irrigation '�f Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> Pump INSTALLATION: Contractor <br /> 1 Type of Pump �. . H.P: / <br /> PUMT'- REPLACEMENT' : I I : State Work Done <br /> PUI�:REPAIR: --�- / i State`-Worktflone �- - `- — <br /> ,f -~... Approximate De th <br /> ;AES TRUCTION OF WELL: Well Diameter `" p <br /> E — Describe Material and`Procedi►re� <br /> I hereby agree to comply with all laws and regulations,'ofithe 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,f1-will;,furnish the San Joaquin .Local Health District e <br /> WELL DRILLERS REPORT of the well an_d 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 INJG ANDA FI AL--INSPECTION''."'' - <br /> s SIGNED / ✓' TITLE F <br /> X' f! (DRAW PLOT PLAN ON REVERSE SIDE <br /> i DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT D B LltV DATE J-�'7 •_ <br /> ADDITIONAL COMNTS <br /> PHAS I GROUT INSPECTION PHAS I INSPECTI <br /> � INSPECTION,BY DATE INSPECTION BY DATE L <br /> t. <br /> _ 1-74 2M <br /> t' E H 1426 Rev. 1-74 <br />