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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telepho 4e : (209) 466-6781 <br /> APPLICATION .FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-6_-77 I <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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/t=ftgj�ft y- CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> i <br /> Contractor's Name License phone <br /> TYPE OF WORK (Check) : NEW WELL - -DEEPEN-/ /—RECONDITION /"/ DESTRUCTION <br /> PUMP INSTALLATIONS/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> ' w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Q IT }PRIVY <br /> SEWAGE DISPOSAL EIELD CESSPOOL/SEEPAGE PIT /496 f OTHER �•� . <br /> PROPERTYLIN RIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED,.USE TYPE OF WELL .y CONSTRUCTION SPECIFICATIONS <br /> Industrial . <br /> Cable Tool_ Da.'a. of Weli °Excavation �. <br /> Domestic/private _�2 Drilled s D a. of Well Casing <br /> Domestic/public Driven Gauge of Casing � j <br /> Irrigation Gravel,;Pack Depth of Grout Seal* N <br /> Cathodic Protection Rotary Type ,of Grout <br /> Disposal Other Other Information <br /> M- _ Surface Seal Installed By: <br /> / <br /> Geophysical <br /> PUMP. INSTALLATION: Contractor f 1/' .jix �� / <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with--all laws and-regula:tlan`s of-Tthe 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 'td-the best ofmy kndcrjedge+and belief. - I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIONS ' <br /> SIGNED E <br /> (BRA7 PLOT P ON REVERSE SI➢E) <br /> PHASE•IFO .DEP TMENT USE. ONLY <br /> ._. �.�- - <,..,�.....__�..._�-_ �, - - �.,.� <br /> APPLICATION ACCEPTED BY "�,,.r DATE AQ"1_5 <br /> ADDITIONAL COMMENTS: x <br /> P SE Ij GROUT INSPECTIO P /FINAL INSPECTI N <br /> SINSPECTION BY DATE (7 INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 �� 0/77 Ana <br />