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E SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 S"o6,j,!9. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 3-) <br /> (Complete In Triplicate') OS'91-I10 t� <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 /> dr <br /> Luc <br /> w JOB ADDRESS/LOCATION SUS TRACT <br /> IIV <br /> Owner's Name c r Phone <br /> _ n <br /> Address `7 city <br /> i <br /> Contractor's Name -�zziekL License PhoneA. <br /> L <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT- /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC '.TANK SEWER LINES PIT PRIVY <br /> SEWAGEj)ISP.OSAL FIELD, .CESSPOOL/.SEEPAGE .PIT, OTHER ; <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i .€s <br /> INTENDED USE � ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia, of Well Excavations <br /> Domestic/private t Drilled Dia, of Well Casing <br /> Domestic/public Driven s y:' Gauge of Casing <br /> 3 :; <br /> Irrigation ' "Gravel Pack V,...r...' Depth of Grout Seal � <br /> Cathodic 'protection ,Rotary Type of Grout <br /> Disposal Other `OtlYer-Information <br /> Geophysical Surface-Seal-_Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 7 H.P. ! <br /> PUMP REPLACEMENT: m /. / State Work Done j <br /> PUMP .REPAIR: State Work Done <br /> Av <br /> DESTRUCTION_ OF WELL: Well_D,iAmeter Approximate Depth <br /> -- - - <br /> Describe Material and Procedure <br /> 4 <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 5 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a 1 <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 f my.k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> - <br /> PRIOR TO GROUTIN AND A FIN PECTIO . <br /> SIGNED a TITLE <br /> E <br /> DRAW Pi T' PLAN ON RE ERSE SIDE) i` <br /> FOR D PARTMENT USE ONLY <br /> PHASE I l <br /> APPLICATION ACCEPTED BY ! DATE �/��Z• <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E DATE ala 3"77 <br /> J <br /> E H 1426 Rev. 1-74 r'.. : . : 3/76 2M <br />