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?''�"-' 'S JOA UIN LOCAL HEALTH DISTRICT <br /> = F-✓ -%= Q <br />" FOE OFFICE USE: 1601' E. Hazelton Ave . , .Stockton, Calif. , <br /> Telephone: ' (209)'466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 3794 <br /> 77- WP)o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued 1 <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. J. <br /> cid S0 U -f" #L y A--Au:`: <br /> JOB ADDRESS/LOCATION � f � o� .-f dsv� CENSUS TRACT&Z"j Gt pfsjj <br /> Owner's Name Phone <br /> - - -� . <br /> Address .. �l _ _ City CAH @ At <br /> Contractor's Name "'//� �1 r,�� �. � �p0 cense #2 �/�lf Phone <br /> TYPE OF WORK (Check) : NEW WEL-L-/.DEEPEN RECONDITION /_/ - DESTRUCTION /_7ALi <br /> PUMP INSTALLATION /i-/ _PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT • OTHER <br /> ' PROPERTY LINE _ PRIVATE DOMESTIC WELL PUB-A-&�'­DOMES-TIC WE - <br /> INTENDED USE "TYPE OF WELL CONSTRUCTION SPECIFICATIONS :> <br /> Industrial Cable Tool Dia, of Well E--;kcivation <br /> amestic/private Drilled Dia, of Well Casing mss/ <br /> Domestic/public--- Driven Gauge of Casing, R <br /> Irrigation Gravel Pack Depth of Grout RZ, <br /> �M .4-y- X=Cathodic Protection -�l�Rotary :Y .- Typq of Grout <br /> Disposal Other Other Information ` <br /> Geophysical ' - � Surf` ce.,Seal Installed By: r <br /> PUMP INSTALLATIM Contractor i Sz <br /> Type of Pum�.,Vk J H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.aPAIR: / / State Work Done <br /> DESTRUCTION OF WELL; Well-Diameter 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 bistrict <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a ew well, I will furnish the San Joaquin Local Health District a <br /> WEL DRILLERS REPORT of the well n otify them before putting the well in use. The above <br /> info on is true to the best my owledge and belief. I WILL CALF. FOR A GROUT INSPECTION <br /> PRIOR UTING AND A FI ION <br /> SIGNED 9 TITLE Q w A --ms s <br /> (D ON REVERSE SIDE) <br /> ' - - FOR DEPARTMENT USE ONLY <br /> PHASE F <br /> APPLICATION ACCEPTED BY ! DATE -/�'7�, <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL TNS E I <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> X77 1 .2m , <br /> E H 1426 s. Rev. 1-74 '. <br />