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C" / twoll <br /> 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.11-905 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-77-1777 <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. 18k2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AI3DRESS/LOCATION Wer1j <br /> caWOW CENSUS TRACT <br /> Owner's Name dl��;t� q�yc Phone <br /> Address /// L�- <br /> f"- � City ? <br /> Contractor's Name rrrJ6 .%''~�t� License # -Phone y ,� <br /> . i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR bC/ PUMP REPLACEMENT /-7 <br /> Other <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 n� <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 /> �, Irrigati6n Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �� p <br /> R <br /> Type of Pump to ,i r!! H.P. so <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> /ZC/ 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 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 m owledge- belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO LZOUTING AND A FINAL I E ON. <br /> SIGNED TLE �/ �• _ i;f <br /> RA PLOT LAN ON RE RSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE rJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. 1 PHASE III4FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 72 <br /> E H 1426 Rev. 1-74 1177 ,: 2M <br />