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` 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 _OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 i <br /> APPLICATION FOR i <br /> WELL CONSTRUCTION OR PUMP PERMITPermit-No.-77-/33Z-- j <br /> ` I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED Date Issued �b/� , i <br /> i{ (Complete In Triplicate) <br /> Application is her made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work (l-Eereiri described. This application is made in compliance with Sari Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION �� er ,r.-.. CENSUS TRACT —-- <br /> Owner's Name 7�� r� b Phone ..�� <br /> Address `�3 2 67111 City ✓_ -- <br /> I <br /> Contractor's Name ,c' orv. � LicenseS ..I'hone_ _ S~ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION DESTRUCTION DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> i DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/go ' OTHER <br /> PROPERTY LINE/Q PRIVATE DOMESTIC WELL '�� PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE -OF WELL s 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 /> Irrigation -Y�' Gravel ;Pack Depth of Grout Seal <br /> -Cathodic Protection - Rotary -Type of Grout <br /> "Disposal '—' Other < Other Information - <br /> Geophysical Surface Seal Installed B ,: /e , <br /> rl <br /> PUMP INSTALLATION: Contractor ` --.. <br /> Type of Pump H.P. .K <br /> PUMP REPLACEMENT: / State Work Done E . <br />" PUMP .REPAIR: �/ / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Material and Procedure i <br /> :IP <br /> I hereby agree to comply with all laws and regulations of the San JoagLiin 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 we11 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 GROUTING AND A11FINAL I SPECTION. <br /> SIGNED TITLE <br /> I� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY � `�, <br /> � �'' <br /> APPLICATION ACCEPTED By DATE0 <br /> ADDITIONAL COMMENTS: <br /> PHASE I NS CTION n P S I/FI I SPECT ON. <br /> INSPECTION BY A D 2r 7� . "INSPECTION B DATE <br /> ® �-� n�77 - rte <br /> E H 1426' Rev. - 1-74 <br />