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0 <br /> a} SAN JOAQUIN,,LOCAL HEALTH. DISTRICT <br /> Fdf, OFFYCE USE: 1'� 1601 E. Hamel jor� Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELIT CONSTRUCTION OR PUMP PERMIT Permit No.77-,3o-E& <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 -2-1-27 <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 Joaquint' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J �1,�` _ Q �L7��yf, //�C4CENSUS TRACT <br /> Owner's Name 2L/c Gl i sOJp-/2, l Phone <br /> Address �� [� City <br /> Contractor's Name XML zt, L cense #4�p00/-7 Phone ',5222-AT9 <br /> .S`aa G11 I <br /> s' <br /> _ f <br /> TYPE OF WORK (Check) . NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> :Other / / <br /> .. i <br /> DISTANCE TOINEA.REST: SEPTIC TANK /o Q SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/S,E�EPAGE PIT OTHER I <br /> STIC WELL <br /> INTENDED USE <br /> PROPERTYLINE <br /> WELLPRIVATE DOMESTIC WELL CONSTRUCTION SPLIC ECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / - <br /> k-- Domestic/private Drilled Dia. of-,Well Casing <br /> Domestic/public Driven Gauge' of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal LS-01 <br /> Cathodic Protection 4—Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:_ <br /> PUMP INSTAI,'IATION: Contractor <br /> Type of Pump H.P. #i <br /> PUMP REPLACEMENT: . / /' -Sdate Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> x 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 Califbrnia peitaining 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 TONG ING AN A FIN NSPECTION. <br /> SIGNED ! i" TITLE <br /> r (DRAW: PL' AN ON RE FRSE SII7E <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY y DATE J ;ZA'27 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION _ AT INSPECTION BY DATE <br /> 3/7b <br /> E H 1426 Rev. 1-74 <br />