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' SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> FOF OFFICE USE: 1�1601 E. Hazelton Ave.,, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-rs9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X77 <br /> (Complete In Triplicate) -ZY 7- ZZ'a—0-V <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. Dtstricta <br /> JOB ADDRESS AOCATION s' '" T CENSUS TRACT - <br /> Owner's <br /> RACT "Owner's Name w Phone <br /> City <br /> Address <br /> . 4 <br /> Contractor's Name !.rlmfg- _ _License # jll Phone <br /> _ z <br /> TYPE OF WORK (Check): NEW WELL DEEPEN_ I� RECONDITION /� DESTRUCTION J AN , <br /> PUMP ENS TION /� PUMP REPAIR / I PiTMI' REPLACSlH31+1T �T N <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 222.,LSEWER LINES 4. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD SSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE ,_PRIVATE DOMESTIC WELL PUBLIC,DOMESTIC WELL <br /> INTENDED USE TYPE F WELL CONSTRUCTION SPECIFICATIONS- <br /> Industrial CablegTooi Dia. of Well Excavation <br /> Domestic/private Dril-IC&I Dia. of Well Casing .. . <br /> Domestic/public Driven Gauge of Casing ` '` `` <br /> I. rri ation Gravel Pack Depth of Grout Seal <br /> I g <br /> Cathodic Protection Rotary'\,!�-, Type of Grout <br /> Disposal Other Other Information �- <br /> Geophysical j Surface Seal. Installed §X: <br /> PUMP .INSTALLATION; Contractor ,, <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP "REPAIR: /7 --State Work Done <br /> DESTRUCTION OF WELL: Well Dia. ter y Approximate Depth <br /> Describe Material and Procedure <br /> I-1hereby agree to comply with all laws-and-regulations-of-the-San Joaquin"--L-ocal-Health-D istr--ict <br /> avid 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 DRILL RT of the well. and notify them before putting the well in use. The above <br /> informat on is trto the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PR10V_2m&VVUT1NGtANrk AtFINSPECTION. <br /> TITLE <br /> SIGN . <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> OR UWARTMENXAJSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYriz <br /> DATE <br /> ADDITIONAL COMMENTS: ` P S FIN INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INS'ECTIOI�J BY DATE INSPECTIONDATE y <br /> E H 1426 Rev. 1--74 <br />