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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7' S�35i' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_S►��3ty, <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED Date Issued 7J <br /> j; (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. 18612 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �, Dom/ b,,6 CENSUS TRACT <br /> Owner's Name <br /> ,ENA 0,E&ER Phone M725 /7 <br /> Address _ rZ�6�6 ` S� CJS/ll� City 1'/1'0A1 t <br /> Contractor's Name 1AlC,, License #2-0 /Phone � <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL f DEEPEN '/—/ RECONDITION /7- DESTRUCTION /_7 <br /> PUMP INSTALLATION IN PUMP REPAIR '/—/ PUMP REPLACEMENT /-7 <br /> .0 her <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 I' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled . Dia, of Well- Casing ✓� �; <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f �� <br /> Cathodic Protection �_ Rotary Type of Grout C� i1oC°A,�sETE <br /> - Disposal Other Other Information ' <br /> Geophysical I� Surface Seal Installed By: AIAQ74C& <br /> 'PUMP INSTALLATION: Contractor A10A G P IAI C, <br /> TYp e of Pump - /a2E'i2 $f��E TUiNE` H.P. <br /> PUMP REPLACEMENT /i. / State Work Done <br /> �I. <br /> PG"MP•�_REPAIR: /:M. / State Work Done ± <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth_ , <br /> Describe Material and Procedure <br /> I ir-reby agree to comply,`,with all laws and regulations of the San Joaquin Local Health District <br /> ani'] 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 .j�the well and notify them before putting the .well in use. The above J <br /> inf6rmation is true to the-best of. my knowledge .and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A E. NAL INSPECTION, <br /> SIGNED TITLE <br /> ��. (DRAW RUT- PLAN ON REVERSE S IDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �l <br /> ADDITIONAL COMMENTS: 0 <br /> PHASE II GROUT INSPECTION PHA IN INSPECTION <br /> INSPECTION BY r"7 <br /> �" INSPECTION BY DATE, tb . 7 <br /> E H 1426 Rev. 1--74�' :.�,4tr /76 2M <br />