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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77-71rW <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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � CENSUS TRACT <br /> Owner's Name 81L1 F�i K Phone <br /> Address . ^ e • <br /> z City <br /> Contractor's Name #iI_=fe �!u Co License # 1/ �„� Phone X3_1 11�IL" <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/7 RECONDITION /-7 DESTRUCTION /L-4r-� <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT %T <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2? SEWER LINES PTT 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 u ; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ` Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /? State Work Done - <br /> ,DESTRUCTION OF WELL: Well Diameter Proximato Dgpth <br /> Decribe Material and Procedure <br /> "it r y <br /> Td � . <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 regulat,iiig will -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 GROUT NG OD A FINAL INSPECTION. <br /> SIGNED / TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYAz& 4 DATE /& <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I PECTTON PHASE TI-j/FI1M INSPECTION <br /> INSPECTION $YDATE _ — 7 -7 INSPECTION BY-7 ATE 7214, <br /> r . <br /> s, E S 1426 Rev. 1-74 1-74 2M <br />