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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77-170 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 a Regulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j CENSUS TRACT <br /> Owner's Name Phone 2— c l <br /> Address .. ,, Cit , ?• . <br /> Contractor's Nam �-r License # (03 Phone -(519 <br /> t <br /> TYPE OF WORK (Check) : NEW WELL /?�DEEPEN / / ECONDITION /_/ DESTRUCTION /'7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> _ Other /% — — <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LjNES ,je-X1- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD F 5� CESSPOOL/SEEPAGE PIT �r-c-L OTHER '---'* <br /> PROPERTY_ LINE - PRIVATE DOMESTIC_ WELL- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gr vel, Pack Depth of Grout Sea d \ <br /> Cathodic Protection otary Type of Grout I , <br /> Disposal Other Other Information 4-os <br /> -Geophysical 5 e Seal/Installed BX: Sha <br /> PUMP INSTALLATION: Contractor i� A,- <br /> Type of Pu H.P. <br /> N, �•, <br /> PUMP REPLACEMENT: / / State Work Done �+ � Y <br /> PUMP REPAIR: / / State Work Done <br /> 1 '. 1 <br /> DESTRUCTION OF, W-ELL:- Well Diameter Approximate Depth <br /> Describe Material._.and Procedure � <br /> I hereby agreez.to comply wifli al:l"laws and regulations of the, San Joaquin Local Health District <br /> and the State�of California pertaining to or regulating well 'c6nstruction. Within FIFTEEN DAYS-'" <br /> after completion ofmy work on a new well, I will-furnish the ,San Joaquin Local Health District a <br /> WEL DRILLERS REPORT of the well and notify them before putting the well in use. The above j <br /> info ion is true to the e f my knowledge;and--b.elie_f. I. WYLL CALL FOR A GROUT INSPECTION s <br /> PRIOR T OUTING ANDA NS MON. <br /> SIG t TITLE ..�N` (1n,� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHAS <br /> DATE <br /> 7, <br /> APPLICATION ACCEPTED BY feC _ <br /> ADDITIONAL COMMENTS: j <br /> PHASE Ty GROUT, INSPECTION PHASE TjgFINAL INSPECTION <br /> INSPECTION BYDATE��- �� ZINSPECTION BY DATE i.,7 g <br /> ! _ � � � P"I d <br />