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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ <br /> /-77- P/T'J,0 i. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 �(s��� �� �� � �_� �X-GENSUS TRACT <br /> ner I s Name __Rp Phonez <br /> �r. <br /> Address WZ City <br /> Contractor's Name �yop\�,i - License # Z5p1fa3Phone �y�-(]3q►.� <br /> �YP <br /> E OF WORK (Check) : NEW WELL '/ DEEPEN RECONDITION RECONDITION / / DESTRUCTION //_77 PUMP INSTALLATION /✓/ PUMP REPAIR/ / PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T `- PIT PRIVY �e � <br /> SEWAGE DISPOSAL FIELD Q -+ CESSPOOL/SEEPAGE-PIT �� OTHER <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 f <br /> Irrigation s ' Gravel Pack -Depth- of-Grout -Seal- <br /> Cathodic Protection Rotary Type of Grout _}�- { _ � _ w <br /> :. Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:,!G w�� ' <br /> PUMP INSTALLATION: Contractor' S' C0 <br /> � x <br /> , Type of Pump <br /> PUMP REPLACEMENT / / State Work Done <br />-'PUMP­!-REPAIR: - "" / / State Work Done - <br /> DESTRUCTION OF WAL:N 'e—We ll Di6am teD0/v a � �< r Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District J <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 /> WE DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> in <br /> tion is true te�TPE <br /> knowledgeand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ROUTING AND FI <br /> SIGNED \ TITLE � p c:) c��-r<- <br /> RA <br /> W ' T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 3 <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: / - <br /> _"""°`"""` 'PHAS I NSPECTIOV. PHASE III/FINAL-INSPECTION_ <br /> INSPECTION BY ATE Z INSPECTION ,BY DATE/z -3F-7;7 <br /> E H 1426 Rev. 1-74 .r 3/76 214 s <br />