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} <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone': (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 lS-76 <br /> : i <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 7 Z!7 � /��� ` <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address 3 z [f 7- City &C A e d.L I <br /> Contractor's Name License #y�L Phone Q44}-S <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN / / RECONDITION_/ / DESTRUCTION /- <br /> PUMP INSTALLATION _Z/ PUN? REPAIR/ / PUMP REPLACEMENT 17 <br /> Other J-1 <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 V. <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 Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical. Surface Seal Installed BY: �W <br /> PUMP INSTALLATION: Contractor ,4"���-� <br /> Type of Pump H.P. 3U <br /> PUMP REPLACEMENT: . / / State Work Done <br /> i' 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> 77 <br /> DRAW ' T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 0 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY LDATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 s <br />