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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF OFFICE USE: CL 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 h <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77 7 - 90 <br /> �. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IN -77 <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .id/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 /> `)B ADDRESS/LOCATION /Rioe 1VA7, Y'_ CENSUS TRACT <br /> n<.mer s Name V) G f U 6 P4 LAI a- /' Phone A- -?305� <br /> dress A/YI {- City Wt ecm✓ <br /> } mtractor's Name �� !A �d ✓c6 License # i7 Phone <br /> kft <br /> 'PE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /—/ DESTRUCTION /-7 <br /> `. PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT A <br /> Other <br /> r <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation �C <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 4 <br /> M Irrigation Graved Pack Depth of Grout Seal `C <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> ,.._Geophysical Surface Seal Installed By: <br /> 'JMP INSTALLATION: Contractor N <br /> _ Type of Pump H.P. <br /> PUMP REPLACEMENT:: State Work Done �rYn ,�� J p � j v , '/" �t <br /> IdMP REPAIR: / / State Work Done X1- <br /> I STRUCTION OF WELL: Well Diameter Approximate Depth <br /> v. Describe Material and Procedure <br /> 7-hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State_9f_ California-pertaining -to or regulating_w.ell 'construction..__Within_FJFTEEN-DAYS <br /> atter 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 /> iformation is true to the best of my knowledge and belief. L WILL CALL FOR GROUT INSPECTION <br /> P+tIOR TO GROUT G AND A FI INSPECTION. <br /> SIGNED to TITLE 0 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ?PLICATION ACCEPTED BY DATE _ <br /> UDITIONAL COMMENTS: <br /> PHASE II, QROUT INSPECTION PHASE II >FINAL INSPECT ON ; <br /> 'VSPECTION BY s j iDATE INSPECTION BY DATE Y/b; [Y / <br /> 1 <br /> 1177 214 <br />