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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOu OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. (' <br /> Telephone: (209) 466-6781 �,�5� _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � _Z7 <br /> (Complete In Triplicate) <br /> application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquir <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> [OB ADDRESS LOCATION CENSUS TRACT <br /> wner's Name Q_ 1 0 1 A yti:e. _ Phone —93 I •- <br /> address ZP r) a City <br /> c+ <br /> :ontractor's Name .�..� !:j�g'�yt �� lry�y� License ll,� ' ;� < Phone _3 6.7_:aj5_Z- <br /> 'YPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /—/* DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /7 _ <br /> ,ISTANCE 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /, v <br /> Irrigation Gravel Pack Depth of Grout Seal ' -- <br /> _ Cathodic Protection Rotary Type of Grout (o-'). . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B A. \� <br /> UMP INSTALLATION: Contractor. ____ _--- <br /> Type of Pump A.P. <br /> UMP REPLACEMENT: /_7 State Work Done FJ <br /> UMP .REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> (ELL DRILLERS REPORT of the well and notify them before puttingthe well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G OUTING D A FINAJ. INSPECTION. <br /> t ��� k AAS'\ TITLE <br /> IGNED <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> 'HASE I �,C <br /> .PPLICATION ACCEPTED BY ,�L../A DATE /02 - / `77 <br /> ADITIONAL COMMENTS: <br /> PHASE I ROUTINSPECTIO P /FANAL INSPECTI <br /> NSPECTION BY /d DATE /a 77 INSPECTION BY ; DATE G 78- <br /> V u 1A9a n„_. , moi. b�77 2M <br />