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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 2466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 3 SSW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Qrdinance.,No. . 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,41 <br /> 14 [ <br /> JOB ADDRESS/LOCATION 'r CENSUS TRACT <br /> HuX »eMoeda/�?y <br /> Owner's Name 111n Zw r da Phone <br /> Address j, F Cit <br /> Contractor's Name c / f License Phone Z --1-/G 1 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL Y DEEPEN /_% RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK jlDNr- SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD AykT.- CESSPOOL/SEEPAGE PIT OTHER AffiV4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool Dia. of Well Excavationr�'' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing V4 aa- <br /> Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout nn�A <br /> Disposal Other Other Information y/ _..._. <br /> Geophysical Surface Seal Installed By: 4242 0 <br /> PUMP INSTALLATION: Contractor Gp Gfin AC.ec6pv S ra�.fil7T <br /> Type of Pump H.P., <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / 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 DAIS <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOri <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE <4 1r1t� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY tDATE 7' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT P II/FI AL INSPECT.ICIN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> e"W ne a -/-?- <br /> E H 1426 Rev. 1-74 0 ?G x '` <br />