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1 SAN JOAQUIN LOCAL�HE�LTH. DISTRICT <br /> FOB OFFICE USE: / 1601 E. Hazelton AV6'0 , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> ' A PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Y77 9�-11J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _y�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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> �T 4tJ&6) PUS TRACT <br /> Owner's Name Phone <br /> Address � Cf��� City <br /> Contractor's Name rLicense # a Q '/ Phone yS,TZ 103 j <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL ZZV DEEPEN / / RECONDITION / / DESTRUCTION /'7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /-7 r <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z5620_! SEWER LINES PIT PRIVY �� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _/ 00 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 _\ /a h _&4 e7zlx. 4) <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION- o r - <br /> C nt actor <br /> Type of Pump H.P. F <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESITRUCTION 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 j <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND INAL W9PECTION. <br /> SIGNEDTITLE <br /> „ rT <br /> (D PL PLAN 'ON REV SE SIDE) °E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,41 DATE _a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE I /FIN INSPECTION <br /> INSPECTION BY DATE 2- OF- Z7 INSPECTION BYDATE Z_ /c/-�'� <br /> (&Jg5) z-a-7-72M <br /> � �' , <br /> E H 1426 Rev. 1-74 `� `/�/_-77 `' aM�-A'` -3 �a avl �,3� 77 <br />