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T <br /> k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -76-F'-OFFICE U5E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PFRMTT Permit No. -77---?371`11 <br /> . e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _h -_7 <br /> ,7 <br /> f (Complete In Triplicate) <br /> ft 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 Joaquii <br /> County Ordinance No. 1862 and e Rul nd Re gu i.a�s of the San Joaquin Local Health District. <br /> e �`� - <br /> JOB ADDRESS/LO ON d CENSUS TRACT <br /> Owner's Name Phon �c J1 <br /> R <br /> Address Ci <br /> r <br /> Contractor's Name �?'�a a. �1,�y., � License # Phone <br /> TYPE OF WORK (Check) :T NEW WELL/ / DEEPEN I / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other ,/-7 <br /> 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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectkon Rotary Type of Grout <br /> Disposal ; _ Other Other Information <br /> Geophysical ' s }� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Don <br /> PUMP .REPAIR: / / State Work Done <br /> E 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 INSPECTION. <br /> SIGNED Q. TITLE JU12 - <br /> D W PI&P PLAN ON RE E'RSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY DATE <br /> C � ,CS , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FIN INSPECTION <br /> INSPECTION BY ATE INSPECTION BY6AJ DATE 8 <br /> a <br /> Iv,, SMPI� rA P 3/76 2m <br /> E H 1426 Rev. 1-74 <br />