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/ e4l SAN JOAQUIN LOCAL HEALTH DISTRICT _ (�1 <br /> FOE OFFICE USE: J 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-67 <br /> APPLICATION FOR WELL CONSTRUCTION 0 IT Permit No. 77, ,2-4S /a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-/g--77 <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 /> JOB ADDRESS/LOCATION/V-- - B P2�friw�lk / 97WA 14j- / c/ CENSUS TRACT h <br /> Owner's Name /t 6� �77//� n p Phone 36 0 6 33 <br /> Address / �o 3 �, ape��—^ " I�� City <br /> Contractor's Name 4DA eZ License Phone ��� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /7 RECONDITION /_/ DESTRUCTION /-] <br /> PUMP 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 LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \z. <br /> Industrial Cable Tool Dia. of Well Excavation 5� <br /> 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 p <br /> Disposal Other Other Information (\\U\ <br /> Geophysicalnn " �r,,�� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor X�.Ci[.[.�t.. <br /> Type of Pump ./ H.P. <br /> PUMP REPLACEMENT: State Work Done P&tp &V_,� <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 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 kn wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A ZIN INSPE <br /> SIGNED TITLE <br /> DRAW POT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ps • ��a �iP� / DATE 3 -16- 7 �7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> E H 1426 Rev. 1-74 376 24 <br />