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SAN JOAQUIN LG!SA Y%EALTH DISTRICT <br /> '� FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. *� <br /> - Telephone,: (209) 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No. 7?_12/W <br /> 77- Cy0 <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 l YlL .. oe g2, j9 ct 4,ffQ CENSUS TRACT <br /> Owner's Name �,,,, . Phone Ij <br /> J <br /> Address w S !'` ``CIN ." City �,�j�"• *-� <br /> Contractor's Nameav t Licenser �d�Q ® 'Phone-74A <br />! TYPE OF WORK (Check) : NEW WELL/;f' DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 4 <br /> PUMP INSTALLATION // / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r + PIT PRIVY ; <br /> SEWAGE DISPOSAL F ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINF.0 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privaten' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /-Z.� <br /> Irrigation ",` Gravel Pack Depth of Grout Seal----4- <br /> F <br /> eal: <br /> Cathodic Protec tion Rotary Type of Grout <br /> F g- Disposal ' Other Other Information ~: <br /> Geophysical Surface Seal Installed_By: <br /> ^4.�y�fy%,fa/ y}•� <br /> PUMP INSTALLATION: Contractor bml V <br /> Type o f Pump'-^�- -„- ,--""'�`H-P-7-7— <br /> PUMP REPLACEMENT: �/ /Y / State Work Done '` {f' <br />`.PUMP '.REPAIR: / / State Work Done <br />`DES;TRUCTION OF WELL: Well Diameter -Approximate Depth <br /> Describe Material and Procedure <br /> f <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 AN A FI'NAL INSPECTION. <br />,,SIGNEDf TITLE <br /> ?_ (DRAW PLOT PLAN ON REVERSE SIDE) .. <br /> FOR DEPARTMENT USE ONLY <br />,PHASE I <br />'APPLICATION ACCEPTED BY � O_ DATE G <br /> 'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE III/FINAL INSPECTION <br /> F INSPECTION BY Tom; DATE 177 INSPECTION BY /, ✓' DATE/2_ -j� <br /> E H 1426 Rev.- I-74 . 1177 : 2m <br />