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f SAN JOAQUIN VOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone : (209) 466--6781. 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77`07 p } <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 16 �S LQ c� CENSUS TRACT <br /> Owner's Name f 114? e—rlGl2 / Phone <br /> Address 14 S� �4 +� -- Gity _ <br /> Contractor's Name License ��/ �j Phone <br /> .TYPE OF WORK (Check) : NEW WELL / / DEEPEN./ / RECONDITION / / DESTRUCTION I=T � <br /> PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER i <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/private Drilled Dia. of Well Casing G� <br /> Domestic/public Driven Gauge of Casing f .. <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical v Surface Seal Installed -By: , <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. / <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done ..- d J a <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 /> k WELL DRILLERS REPORT of the well and notify them before putting the well in use... The above <br /> I information is true. to the best of. y owl dge and belief. I WILL CALL FOR A GROUT INSPECTION <br />° PRIOR TO G U ING AND A FTNkL_jMVE ON 10 . <br /> _ TYLE _ Ole- <br /> SIGNED fl _-. <br /> ` (DW PLO PLAN ON RWERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY- DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I/ NAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY DATE . C7 <br /> 6/77 _ 2M <br /> E H 1426 Rev. - I-74 ' <br />