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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> • D- r'OFFICE US 1601 E. Hazelton Ave. ,-,Stockton, Calif. <br /> - Telephone: w(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> HIS PERMIT EXPIRES 1 YEAR FROM�DATE ISSUED Date Issued <br /> Td l-J -77 <br /> (Complete In Triplicate) <br /> 4pli.cation is hereby made to the San Joaquin Local Health District icor 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 shd Regulations of Che San Joaquin Local Health District. <br /> JOB ,ADDRESS/LOCATION1 ZEL 1 f.,.�AIA l CENSUS TRACT <br /> Owner's Name Phone - 77 <br /> Address• 2' 'J W//),K City IIISL7MfWAI <br /> Contractor's Name l - p, License Phone leLX-6-5'77 <br /> 1 <br /> TYPE OF WORK (Check): NEW WELL L DEEPEN /-7' RECONDITION".'/-7r'D]ESTRUCTION f7 <br /> PUMP JNSTALLATIONM / . PUMP REPAIR /� PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT, PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHERe <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL . ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> X _ Industrial\ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/pilblic Driven Gauge of Casing J,z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By 1/1//I/6W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> . <br /> PUMP REPLACEMENT: / / State Work Done <br /> — <br /> PUMP .REPAIR: 17 State Work Done <br /> i <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material-'and Procedure - <br /> 1 <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 i <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 aiid`belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GG A' FINAL INSPECTION: S <br /> SIGNED — 'TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 7` <br /> PHASE II GROUT INSPECTION PHASE IIILFINAL INSPECTION <br /> INSPECTION BY DATE - m <br /> INSPECTION BY DATE Z Z7 <br /> t^ <br /> E H 1426 Rev. 1-74 <br /> 1-74 <br />