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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77;I0,-4J <br /> 77-7-YO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -Issued 2_-2- 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/L•®@ft-14M CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address City ; <br /> Contractor's Name <br /> y, �� �"� License hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> f-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/!2e POTHER <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/privateA----Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> ' Gauge of -Casing <br /> Irrigation Gravel Pack Depth`of Grout, Seal d �- <br /> Cathodic Protection A--"- Rotary Type of Grout <br /> Disposal Other Other Information. <br /> Ceophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump zkz=ffE - H.P. <br /> 1 Y' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done r r <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 FINAL INSPECTIO / <br /> SIGNED LE „� �"/ 41 <br /> ( W PLOT' PM ON REVERSE SIDE) j <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I �,. .. •..a—.�- .�...�. . .:. ...�. <br /> 7/7 -7 <br /> APPLICATION ACCEPTED"`BY T DATE 71-1 <br /> R <br /> ADDITIONAL COMMENTS: <br /> PHASE"'IIGROUT-IN PECTI_ON, „ �.a _„ _.. .-��u-- P E 4�I/JgNAL INSPECTIO <br />'INSPECTION By 2_0_2� DATE ? - --------- N.SPECTION BY. • DATE —t/7-7 <br /> E H 1426 PpV_ 1-7L . , 1/77 - 2M <br />