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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -7,7-101 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77--2 Y01 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I-/o - 7 7 <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 /> Cozen y Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> LO.2-IA? �/ Lei f °Lf A-Ile-... .,J. <br /> JO ADDRESS/LOCATION p N.r`Pa-y-5'c, tew CENSUS TRACT <br /> Owner's Name 61 91-- Phone <br /> Address31R)� �. �iv,�- Y- �. �� City �" CCS <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN _% RECONDITION / / DESTRUCTION /_ <br /> 'PUMP INSTALLATION f PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 0 <br /> SEWAGE DISPOSAL FIELD /*W4r_,CESSPOOL/SEEPAGE PIT OTHER ^Q <br /> PROPERTY LINE - MEL PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> -- i; Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C4A� <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed By: 0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump � H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 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 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 .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 /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE <br /> D y+7 'L-T PLAN ON RE ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS , GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 712 <br /> INSPECTION BYE DATE INSPECTION BY DATE �. ��� <br /> E H '1426`,.Rev. 1-74 3/76 2M <br />