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r <br /> �� fF <br /> JOAQUIN LOCAL HEALTH DISTRIC <br /> FOF,'aFFICE USE: 1601. a. Hazelton Ave. , Stockton, Califf". f ✓ <br /> Telephone: (209) 466--6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP-PERMIT Permit No. 7,7- /a-/cJ <br /> 77-la3 <br /> ) � THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUE Date Issued -/S 77 <br /> (Complete in Triplicate) <br /> Application 'is hereby made: to the Saiz Joaquin Local Health Distr t for a permit to construct <br /> and/or install the work herein described. This application is d6e id.compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of ati -Joaquia Ea4% ?Tct. <br /> .SOB ADDRESS/LOCATION � ioa E r� &SUS TRACT <br /> Owner's Name -_H_►z-r Tb -_ey J AG W '` leo cite - 3� <br /> ► Phone 7 <br /> Address 3141 E L)E 40c, City E�sCaLo N. <br /> Contractor's Name I.AF✓ LO. License # 2/0Sg2. Phone,52 '2--7S <br /> TYPE OF WORK (Check): NEW WLL 1W DEEPEN '/_7 RECONDITION F7 . DESTRUCTION /_7 <br /> PUMP, INSTALLATION �/ PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> a Other <br /> DISTANCE TO NEAREST: SEPTIC TANK3_;5j2 SEWER LINES. PIT PRIVY a A <br /> SEWAGE` DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .-- PRIVATE DOMESTIC WELL' PUBLIC DONJ C WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Dia,. of Weil Caeirg .. =R." <br /> :.. <br /> Dd&6 is/public Driven -Gauge of Casing <br /> _-X Irrigation Gravel Pack Depth 'of Grout Seal <br /> Cathodic Protection Rotary Type of Grout dl¢ya� i „ <br /> Disposal Other . Other Information <br /> Geophysical Surface Seal Installed B -. <br /> PUMP INSTALLATION: COntractvr . /� <br /> Type ;of Pump , H.P. 7377 <br /> PUMP REPLACEMENT: • / /. :.,State -Work Done. <br /> POMP REPAIR: tate Work Done <br /> [3E&TRUCTION OF WELL: . Weil Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply wi.th, all laws and regulations of .the San Joaquin Local Health District <br />' And••-tlie- State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br />' after. .completion of my work an anew well, I will furnish the San Joaquin Local Health District a <br /> WELL-ARILLERS _REPORT of. the_*el. and notify them before putting the.-well. in-use.... .The above <br /> information is true to .the-best -of- my..knowledge and belief. 1 WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTINR D AVIyAL INSPECTION. <br /> SIGNED ITITLE So <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> DEP TMENT USE ONLY <br /> PHASE I j <br /> APPLICATION ACCEPT Y ' L//1f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHAS III AL INSPECT INSPECTION BYE BYE DATE INSPEC ION BY DATE <br /> / G - <br /> E H426 <br />