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�y <br /> 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 <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 Joaquin <br /> County Ordinance po. 1862 a d the Rules and Regulations of the San Joaquin Local Health District. <br /> G <br /> JOB ADDRES� OCAT ON V, .0q <br /> 0 �CENNSSUS TRACT <br /> o <br /> Owner's Name �(.� n Phone <br /> Address City <br /> ^ Contractor's Name ULicense #,_24Z Phone <br /> i TYPE OF WORK (Check) : NEW-WELL/ / DEEPEN / / RECONDITION_/ / DESTRUCTION ro(7 044, •���',,. <br /> PUMP INSTALLATION -%// PUMP REPAIR / / PUMP .REPLACEMENT / <br /> Other '/_7 — — <br /> a` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 �� <br /> Domestic/public Driven Gauge of Casing. <br /> * xrigatian Gravel 'Pa.ck Depth of Grout Seal <br /> a Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information � <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pubp • H.P. <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 regulationof 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 riotify 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 GRO TING ANDA INAL INSPECTION. <br /> SIGNED TITLE `' 'L <br /> Il-INW7.I'. 'T PLAN `ON REVERSE SIDE) 1; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ._.....,,,.: `•��"; <br /> APPLICATION ACCEPTED BY.. DATE S'-/ <br /> ADDITIONAL COMMENTS: `: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S%3:�'7 <br /> <-. 3/76 ltd <br /> E H 1426 Rev. 1-74 <br />