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� S. JOAQUIN LOCAL HEALTH DISTRICT <br /> BOE OFFICE USE: J 1601'"!' Hazelton Ave. , Stockton, Cali <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-J 7714 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77-410 <br /> 71 4p <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/L �,'PQ ScF �// � /� CENSUS TRACT <br /> Owner's Name ��J�S. �d� /yl�{�. / V Phone <br /> Address <br /> City <br /> Contractor's Name f71' �t� !N es License J (6Phonej5;L3 J'�LLa <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 10Q SEWER INES S70 PIT PRIVY ---- <br /> SEWAGE DISPOSA �ELD +CESSPOOL/SEEPAGE PIT �G 'OTHER <br /> PROPERTY LINEZSPRIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELLS <br /> INTENDED USR 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 /�'pa <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �716r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor X /gY5 <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done p� <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 REP(MT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI / _ L <br /> SIGNED ITLE L-fT� r r <br /> W PL T P AN ON REVERSE SIDE) <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 610 DATE y / S <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1177 2M <br />