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_ 6J)d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton 'Ai6., k Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :27-V/S_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <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 Z = CENSUS TRACT <br /> Owner's Name Phone <br /> Address �- ctc_'14 -1, byCity <br /> Contractor's Name _ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /, DEEPEN/_/ 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 =---41&VATE DOMESTIC WELL PUBLIC DOMESTIC WELL \� <br /> INTENDED USE TYPE OF CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable T&o1W Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 7 f <br /> Dome stic/pubicDriven Gauge of Casing <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 By: OLhtpi� <br /> PUMP INSTALLATION: Contractor di <br /> Type of Pump Ta-A" p - H.P. '7 i <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth +` <br /> m <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 t ro the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ING AND A FINAT, INSPECTION. <br /> SIGNED !r /. TITLE .. <br /> MAW/MVPLAW ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C..f/ DATE �Z lS 77 <br /> AD ITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE II FIN INSPECT ON <br /> APECTION BY DATE INSPECTION BY,. DATE ZI <br /> E H 1426 Rev. 1-74 376 2M <br />