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✓� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: U 1601 .E. Hazelton Ave. , Stockton, Calif. _ - � <br /> . � Telephone: (209) 466-678 . 77 <br /> E' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ���d t`1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE _ISSUED Date Issued 3- 5 -77 <br /> (Complete In Triplicate) <br /> Application is hereby shade 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, CENSUS TRACT <br /> Owner's Name _ �. �� � � Phone <br /> 5e-Ir <br />` Address — .� City <br /> Y Contractor's Name p License hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL Piz, DEEPEN '/ / RECONDITION f_1 DESTRUCTION /7 <br /> PUMP INSTALLATION`): PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other'/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ior <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> A PROPERTY:LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v . <br /> Industrial .t Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well.Casing a r <br /> Domestic/public — Driven `Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout _ <br /> _74- <br /> Disposal Other Other Information <br /> Geophysical Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor G9 <br /> Typeiof Pump <br /> ' H.P. <br /> 'It _ <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> r <br /> PUMP .REPAIR: / / 'State Work Done <br /> DESTRUCTION OF WELL: Well�Diameterl I Approximate Depth <br /> Describe Material and Procedure <br /> t <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 shy work 'on a new well,_I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS' REPORT t e well'and ,notify them before putting the well in use. The above <br /> i information is trito the best of, my..k owledge and belief. I WILL CALL FOR A GROUT INSPECTION f <br /> } PRIOR TO GRO NAI, INS <br /> SIGNED I TITLE <br /> x DRAW Pi. T' PLAN ON REVERSE SIDE , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY �~ ' . - DATE <br /> k ADDITIONAL COMMENTS: e21 6f <br /> P SE i OUT I SPECTIO / PHASE I/FI INSPE ON <br /> INSPECTION BY DATE INSPECTION BY J DATE <br /> E H 1426 Rev. 1:-745�`ll" <br />