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!� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFI USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z7—n-il,� <br /> V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -77 <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. 1.862 and the Rules and Regulations of the San Joaquin -Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Yf . Phone <br /> Address �„ -✓ City <br /> Contractor's Name �.,. _� License #/2±2, hone 56Ek247d <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /Sc/ PUMP REPLACEMENT <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �+ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> )C Domestic/private Drilled Dia, of Well Casing (� <br /> Domestic/public Driven Gauge of Casing IN <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: <br /> 4 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done azoo <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 my nowledge and--belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT <br /> SIGNED _ <br /> RA POT PLAN ON RE SE SIDE) --rt <br /> OR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE P <br /> ADDITIONAL COMMENTS: <br /> PHASE II OU IN ECTION PHAW PfI/VNAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE S 7' <br /> E x 1426 Rev. 1-74 <br /> 1177 2M <br />