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SAN JOAQUIN LOCAL HEALTH DISTRICT rr <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. YJO <br /> Telephone: (209) 466--6781 -77-170 <br /> 77-17 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �c./ <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueEC 28 1977 <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 /> I A <br /> JOB ADDRESS/LOCATION 1 CENSUS TRACT <br /> II j� <br /> Owner's. Name ,�t9 E .C�.t �7`E.�d -- _ Phone . <br /> l <br /> Addressi City <br />[ Contractor's Name ' License ���?��//Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ RECONDITION_/_/ DESTRUCTION /-7PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — PIT PRIVY <br /> SEWAGE`DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -- <br /> PROPERTY LINIYa PRIVATE DOMESTIC WELL"/2! PUBLIC DOMESTIC WELL �- <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia, of Well Excavation <br /> Domestic/private i Drilled a Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation �y Gravel Pack Depth of Grout Seal f \ <br /> Cathodic Protection Rotary Type of Grout xw Ar <br /> a Disposal t Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contr Ictor �I� <br /> Type aFf Pump r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ <br /> ' <br /> i <br /> PUMP •.REPAIR: / / State Work Done <br /> ' DESiTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 4 Describe Material and Procedure <br /> I hereby eagree to comply with all laws and regulat•ions-;-of-the.4Sant Joaquin Local Health District <br /> land the- State of California pertaining to or regulating welleonstruction. 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 we 11. 'in use. The above <br /> information is true to the st f- my awledge and belief. I WILL CALL FOR A_GROUT INSPECTION <br /> PRIOR TO O A FI P ON. <br /> SIGNED TITLE -&941 -- -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Q"�2��>' '�--�-� <br /> ADDITIONAL-COMMENTS: - <br /> _�._ <br /> pHAU II G ;I ECT ON` PHASEIII/FINAL- INSPECTION , <br /> INSPECTION BY: r DATE <br /> i INSPECTION,•BYa TE -;. ,7rf_. <br /> E H 1426 Rev. 1--74 <br /> . 117.7. <br /> k _ <br />