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CO five �a a�r� dC ' SAN'JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOF.OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-5'33 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .r f-,77 <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 hereiiz described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Loc Health District <br /> .--�JJ4 1 <br /> JOB ADDRESS/LOCATIONIps .ea "sCC( CENSUS TRACT <br /> Owner's Name �A!+'L �t Phone <br /> E <br /> Address a S 3' City <br /> 'E <br /> Contractor's Name zz. 44License # L� 72�A Phone <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE 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 /> Iomestic/public Driven Gauge of Casing 3 <br /> rrigation Gravel- rack - Depth of Grout -Seal \ , <br /> z ` T V <br /> Cathodic Protection Rotary , Type of Grout <br /> Disposal Other :Other Information <br /> = Ceophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> H.P <br /> Types_of Pump,_ , <br /> v <br /> PUMP REPLACEMENT: / / State Work Done­ <br /> 4u <br /> PUMP .REFAIR: / State Work Done i�'" ,�. <br />` DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply.with all laws and regulations of the San Joaquin Local Health District <br /> and 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 /> WELL DRILLERS REPORT of the well and notify thein before putting the- well in use. The above <br /> information is true to the best o �y now edge`'"And belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GLOVING AND A FINAL INSP TION. <br /> SIGNED 1 TITLE , <br /> (D W'PLO AN ON ERSE SIDE} <br /> NIF FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '' "T <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ..', PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �{ <br /> ' 1177 _ 2M <br /> F H 7426 Rav_ 7--74 _ _ _ <br />