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i� C <br /> � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i; Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit; No. 7 7-437 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -.-,�Z- <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 :Wade in compliance with San Joaquin <br /> E County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSB* i 2 6�Y�• CENSUS TRA11 T <br /> � <br /> Owner's Name ® pl ay Phone I <br /> Address li City <br /> Contractor's Name �' � ¢'l License /� �QPhone <br /> tr I� <br /> P. TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION /-7 DESTRUCTION /-71E <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other El <br /> DISTANCE TO NEAREST•: ,,;,-SEP-,TIC -TANK SEWER LINES �Cf. .PIT. PRIVY. "r � x <br /> SEWAGE DISPOSAL X1ELD ,7S-() c� CESSPOOZ/SEEPAGE PTTTl�OY-OTHER <br /> PROPERTY LIN96 PRIVATE DOMESTIC WELL�00 (PUBLIC DOMESTIC_ WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT ONS C� <br /> .Industrial: u Cable Tool . Dia. of ,Well Excavation 7 IX7 <br /> Domestic/private II Drilled , Dia.-"of�'Well -Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 0 Gravel Pack Depth of Grout Seal . _ <br /> Cathodic Protection Rotary_r,@, �.� _.,. Type.,of Grout <br /> Disposal Other Other Information �M <br /> Geophysical �i Surface Seal Installed By: <br /> �i i <br /> PUMP INSTALLATION: :Contractor -4 <br /> !,Type of Pump ` H P. <br /> PUMP REPLACEMENT: . r/ / State Work Done <br /> ` H <br /> PUMP .REPAIR: f / State Work Done ' .. <br /> DESTRUCTION OF WELL: nWell Diameter �a-- 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 /> k and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my�iwork on a new well, I will furnishYthe San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -we ll1`in use. 11 The above <br /> information is true to'ithe-best of my knowledge and belief. ,,i WILL CALL FOR A"GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN E ON. y J Ir <br /> SIGNED i <br /> DRAW 'P T L ON REVERSE SIDE) I , <br /> FOR D ARTMENT USE ONLY <br /> PHASE 'I <br /> i <br /> APPLICATION ACCEPTED BY /t�' "- `V DATE <br /> ADDITIONAL•COMMENTS: '' '� <br /> PHASE II ROUT SPECT.IO PHAS I/FI AL' iNSPEC I N; <br /> INSPECTION BY DATE �INSPECTION BY DATE <br /> ..�.� .� . <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 ' <br />