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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-S�1, 41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S2LZ17 <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. <br /> JOB ADDRESS/LOCATION 31 e ,3 / CENSUS TRACT <br /> Owner's Name Phone 3 <br /> Address City <br /> ' t _ License # I2 4 2S Phone <br /> Contractor's Name ir+0. �r �rf t� <br /> i <br /> TYPE OF WORK {Check} ; NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q 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 SPECIFICAT NS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing - - <br /> Domestic/public Driven Gauge of Casing ��^1or C <br /> "Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout p�� i <br /> Disposal Other Other Information I to <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 41. H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> Y <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF- WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 or 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' G N D F AL INSPECTION. f <br /> TITLE <br /> SIGNED - i/•c.r17-���` ---.t,-:, <br /> �. <br /> W PL T PLAN •ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE IN GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> r INSPECTION BY DATE _ INSPECTION BY DATE ; <br /> 3/76 2M <br /> r 71 1/.7ti Rnv. 1_7Li a: - <br />