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SAN JOAQUIN LOCAL HEALTH DISTRICT A P/v! . )i45_j q0_05 <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-,1-) '7t4/ <br /> 77- P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ZM RIQY S//VA A L Lam,.._.,. . ..,._,. ,_,--- ---- Phone .,ezl3 f <br /> Address /L GEO Ah City <br /> Contractor's Name __A10, QCT -,/�U/d'I/7._S //VC. ^ License #2_ppZgjPhone <br /> TYPE OF WORK (Check) : NEW WELL y _DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> &/ <br /> PUMP. INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <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 /> Domestic/public Driven Gauge -of Casing -/,o 6A, -� <br /> Irrigation J Gravel Pack Depth of Grout Seal �4/0x/E � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ N��� 2!2(M'Od sS //!!C. <br /> Type of Pump H.-__ H.P. /fJ aP. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 them before putting the well in use. The above <br /> information is true to the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING' AND A FI AL INSPECTION. <br /> SIGNED TITLE <br /> !',(DRAW- PLO <br /> T' PLAN ON REVERSE SIDE " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a� � DATE 12 17 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2m <br /> I'E H 1426 Rev. 1-74 <br />