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fes, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF_ OFFICE USE: 1601 E. Hazelton Ave; , Stockton, Calif.' <br /> Telephone : (209)' 466-6781 <br /> rAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' Permit No. 77 yJl, cJ <br /> THIS PERMIT:EXPIRES 1'YEAR FROM DATE 'ISSUED ' Date 'Issued �-,L-JZ' <br /> i.� -(Complete "In Triplicate) 3 <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., 1862 and the Rules -and Regulations, of the San' 'Joaquin Local .Health. District. <br />'r JOB ADDRESS/LOCATION CENSUS TRACT , <br /> Owners Name . 1 - Phone _ <br /> Address9- - s t f �. Cit J� <br /> X Y <br /> Contractor's Name ' r}. ! N License 4� , Phone <br /> ' . <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /'/ RECONDITION -/ � <br /> _I: DESTRUCTION / f <br /> b PUMP INS.TAANON / ./ :.:PUMP"_ REPAIR /. / .... PUMP_REPLACEMENT. /_7 <br /> . • Other -/ / [ - <br /> DISTANCE TO NEAREST: SEPTIC- TANK 7r - SEWER LINES ISO` PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - =PRIVATE DOMESTIC WELL 'PUBLIC: DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ . CONSTRUCTION SPECIFICATIONS - <br /> Industrial i : -. Cable Tool: `F ti• Dia. of Well Excavation <br /> _]ZDdmestic/private EI Drilled Dia. of_Well.Casing <br /> Domestic/public :` L'' Driven Gauge of Casings <br /> Irrigation , . -r 3 Gravel Pack Depth of Grout Seal. d f <br /> Cathodic Protection k / otary Type of. Grout rF . Ek f-^ <br /> Disposal �i � 4 Other. i Other Information t <br /> Geophysical k Surface Seal Installed B :� <br /> PUMP INSTALLATION: i ,. Contractor -Type'.-.of. .Puinp H.P.. C <br />'`PIMP REPLACEMENT. <br /> % / State'Work Done <br /> PUMP REPAIR: a / / State' Work Done <br /> DESTRUCTION OF WELL: WellDiameter ' Approximate Depth <br /> Describe Material and Procedure <br />' I hereby agree`to comply with all 'laws and regulations ofzthe San Joaquin Local Health District <br />',and the State of California -plertaining to or regulating we1-1 "construction. Within FIFTEEN DAYS <br /> arter'xcompletion -of my work on a.-new well, I .will' fur-nish-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 GROUTI 'AND 'F NAL INSPECTION. <br /> SIGNED �. ---, :� TITLEtii--rc.�. . <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />'APPLICATION ACCEPTED BY K �. DATE `7� <br /> ADDITIONAL COMMENTS: <br /> k PHASE II GROUT INSPECTION / P I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 '., 1/77 2M <br />