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F'-T JOAQUIN LOCAL HEALTH DISTRICT <br /> �0R OFFICE USE: 160 . Hazelton Ave. , Stockton, Ca . <br /> l <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z77Lr3� <br /> THIS PER14IT EXPIRES l YEAR FROM DATE ISSUED Date Issued / ", <br /> (Complete In Triplicate) <br /> L)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 Joaqui. <br /> County Ordinance No. 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> LB ADDRESS/LOCATION tees+ cc� d d F Jnt ,j4- W10 4 r0tleC, SAe_rpCENSUS TRACT <br /> 4 Pr--r -,Vf-r4Cr+t ' <br /> ' -7ner's Name 1711- �: • Phone <br /> i <br /> dress % City <br /> 50a Joaquin Pump Co. r <br /> i mtractor's Nam Of 59n_1ooyO,•A 1Sufpher Co.) __...,.__._.�_.... <br /> License # 3/D3 79 Phone j � <br /> 711 N <br /> S PE OF OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 _ <br /> L PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /+ <br /> Other / f <br /> I STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f L Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> M Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> tJMP INSTALLATION: Contractor <br /> L Type of Pump H.P. . <br /> r'7MP REPLACEMENT: /Mate Work Done <br /> MP REPAIR: / / State Work-Done <br /> VS•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Lhereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d 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 /> "��IOR <br /> LL DRILLERS REPORT of the well and notify them before putting. the well. in use.. The above <br /> formation is true to the best of- my knowled and belief: I WILL CALL FOR A GROUT INSPECTION <br /> I TO GROUTING D INAL.,I SP an ,oaquen PumpCo. <br /> (�RIGNED TITLE (Division of San Joaquin Sulphur Co,) <br /> L <br /> -(DRATT PLOT PLAN ON REVERSE SIDE) acramento t. <br /> F DEPARTMENT USE ONLY `' <br /> PHASE I <br />} LPLICATION ACCEPTED BY J DATE 7 <br /> DITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION V PHAS I/FI INSPECTION <br /> 1 �ISPECTION BY DATE INSPECTION - ATE <br /> 1_7A 6/77 2M <br />