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! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE: OFFICE USE: 1 1601 Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S//-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 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 / � ��� /j// ,� CENSUS TRACT <br /> Owner's NameT"rrai c��c- 7-uri�CT�S (��t/ one D <br /> WC <br /> Address /g /.1,� �/ /Z Z% City / <br /> Contractor's Name /4 g Al,()OO (1,ZeC /� License # Phone—VO-Viz-7 <br /> TYPE OF WORK (Check) : NEW WELL 97- DEEPEN%/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION K/ PUMP REPAIR/ ME <br /> / PUMP REPLACENT /7 <br /> Other -C <br /> DISTANCE TO NEAREST: SEPTIC TANK °� SEWER LINES /b-() PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC ONS r�. <br /> Industrial Cable Tool Dia. of Well Excavation W <br /> Domestic/private Drilled Dia. of Well Casing /,7!�U / <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ZZW,4,G <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 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 REPORT 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 GRO TING AND A FINAL INSPECTIOF. <br /> SIGNED TITLE <br /> :IKDRAW PLbT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTAN PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - (2 77 INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />