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JOAQUIN LOCAL HEALTH DISTRIb <br /> FC3 :OFFICE USE: r 16L E. Hazelton; Ave. , Stockton, Cai�i. <br /> Telephone: (209) 466-6781 V4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7-7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued 6 7- <br /> (Complete <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 Joaqui <br /> County Ordinance No. 1862 and the Runes and Regulations of the San -Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 4v CENSUS TRACT <br /> Owner's Name % G C_QPlfne <br /> Address /3 A/ a City , 6 <br /> Contractor's Name /A/C License #ZfO /3 Phone] -//P, <br /> TYPE OF WORK (Check): NEW WEZ:T.3'/V� DEEPENit RECONDITION % f DESTRUCTION ° <br /> PUMP INSTALLATION PUMP PAIR /7PUMP REPLACEMENT <br /> Other '; (�o <br /> I" l <br /> DIST TCE B N S KpIr <br /> TANKJ.S.O ,, SEWER LINES/3,,�! PIT PRIVY <br /> "S, ISPOSAL FIELD CE PIOQL/SEEPAGE PIT <br /> OTHER <br /> PROPERTY'iINE -- PRIVATE DOMESTIC. WELL PUBLIC DOMESTIC- WELL <br /> XNIEHRED USE $ OF WELLCONSTRUCTION SPECIFFCATIONS <br /> IndIndustrial Cable. Tool Di": .k. of Well Excavation <br /> Domes lc% rivate - Drilled ,Dis. of Well Casing � <br /> �/ Domestic public :r Driven f <br /> Irri fioni „ ge of Casing c Sea.*1 La <br /> i .. { , Gravel PackDepth of Grout Seal <br /> Cathodic Protection Rotary Type of Grot <br /> '- 0 _ G:"G,at r.v <br /> Disposal <br /> ri.. Other _ Other Information ' ' <br /> f Ceoph6ic Surface Seal Installed B <br /> PUMP INSTALLATION: ` <br /> Contracttor <br /> Type of:'-pump <br /> PUMP REP <br /> LACEMENT: / / State Work Done; ,. <br /> PUMP .REPAIR: 1-7 State Work Dobe . ., Y <br /> k <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approxi ate Depth 4� _D scrYb ; ter `1Ta -YP o educe <br /> 12 <br /> I hereby agree to comply ith al laws at: .regulatpns ofthi .7oaqu3i ` ocal Health District <br /> and the State of Califbrinia P ;;regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my.• work on a new well,. .wi<41 raish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT df 1tfie weld-.and noti$ them'be ore putting..the..well in use.. . .The above <br /> information is true to ihe,best.of.m, . k4o edgq. and be-lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUPING AND 4A'FINAL INSPECTION. ' `A ` <br /> SIGNED TITLE <br /> f DRAW LOT P ON REVERSE SIDE <br /> FOR PAiTMENT USE ONLY <br /> PHASE I <br /> APPLICATION CATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ` DATE <br /> PHASE II GROUT INSPECTION `` PHASE" III .INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE =!; <br /> E H 1426 otr_ .1_?/. <br />