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V)W SAN JOAQUIN LOCAL. HEALTH. DISTRICT <br /> FOE'OFFICE USE 1601 E. Hazelton Ave., Stockton, Calif. ; <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-� Lr� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to constiruct ' <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. ! i CENSUS TRACT z`f1" jam` <br /> Owner's Name Phone <br /> Address <br /> • � City <br /> Contractor's Name wS 1 CA LicenseQ Pi�aae f�Q ( <br /> •3 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/_/ RECONDITION /-7 DESTRUCTION /-7 <br /> . PUMP INSTALLATION / / PUMP REPAIR 17 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �j �SEWER LINES {- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOM Tr WELL UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION '000'- <br /> Industrial 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 Seale - <br /> Cathodic Protection Rotary Type of Grout --- �� <br /> I <br /> Disposal Other Other Information <br /> Geo cc j, r <br /> Geophysical P y Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 wifh all laws and regulations of the San Joaquin Local Health bistrict <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 j <br /> PRIOR TO GROUTING AND. A FINAL INSPECTION. <br /> SIGNED 1 F 'y _ C4 b&jTITLE <br /> DRAW PLOT FLAff ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ? �J <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHAS I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B�Y�� - DAT -7 <br /> E H 1426 Rev. 1-74 � ��/C C/7 7 �r �� (7 Yl 214 <br />