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; �41 SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- <br /> 77-S75 <br /> o. 77-S75 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .:C- d_7 <br /> ' (Complete In Triplicate) <br /> Application is' tereby 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 ��fi.]� �• (I CENSUS TRACT <br /> 9 � <br /> Owner's Name QQ -� Phone <br /> Address �� � lllfV City <br /> Contractor's Name (,� l� �[J License PhoneZ� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL . DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /4 PUMP REPAIR/ / PUMP REPLACEMENT /7 j <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z�` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EEPAGE 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 ! 1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sealy <br /> Cathodic Protection _L/Rotary Type of Grout 6� <br /> Disposal Other Other Information ✓ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1C/kc- HCl <br /> Type of Pump. Rl� " L 0 H.P. <br />; PUMP REPLACEMENT: / / State Work Done <br />» PUMP .REPAIR / / State Work Done <br /> DESTRUCTION OF WELL: Well•oD-iameter 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 we11 'construction. Within FIFTEEN DAYS <br /> aftet 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 /> IPRIOR TO GROU ING ANP2A FINAL INSPECTION. <br /> SIGNED f TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> If PHASE II GROUT INSPECTION PHASE U;/FIN INSP CTION <br /> INSPECTION BY DATE INSPECTION BY ,, DATE 10-2 --77 <br /> E H 1426 Rev. 1-7-4:. V i� <br />