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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_Z-A-1 <br /> 7 n. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'_27-77 <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'-deatribed. 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 ' � a�' � (° CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address � _^-tee:. <br /> � -- „ <br /> r C�� <br /> Contractor's Name License Phone <br /> € -- <br /> �I <br /> i <br /> -21 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION / <br /> /- <br /> PUMP INSTALLATION /,7;?/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST:-- SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEE AGE PIT OTHER <br /> PROPERTY LINE - PRIVATE ]DOMESTIC WELL � PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial [ Cable Tool. - Dia. of Well Excavation .. 7 40 <br /> mestic/private .1 Drilled Dia, of Well Casing S � � <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed n : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �r+ l.-C.t_ H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 st of my know ed and be f. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A N CT ION s ttt <br /> SIGNED <br /> E <br /> ( (D W PLOT P AN ON REVERS SIDE) <br /> PHASE I­ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY !1 DATE <br /> ADDITIONAL COMMENTS: --- — <br /> PUASW N CTI N PHASE JAIFINAlo JA/FININSPECTION <br /> INSPECTION BY ' INSPECTION BY DATE <br /> y r5 <br /> E`H 1426 I eevv.l I(-7 <br />