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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j I Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' I 77-'-6s p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -77 <br /> Application is hereby made (Complete In Triplicate) <br /> to the San Joaquin Local Health District for a permit to'construct <br /> County Ordi <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ri <br /> PL/ ;� �:E{ 1,-, ! c7 c CENSUS TRACT <br /> Owner's Name ! (2 + <br /> � �/l03 Phone 36 Y,a3 <br /> 3 � <br /> `` Address <br /> I 1� City <br /> Contractor's Name `�%� V. � License � 6137.3 phone .may <br /> i I L-,—IPI? i <br /> . TYPE OF WORK (Check) : NEW WELL /% DEEPEN / / RECONDITION / / DESTRUCTION /-7 1 ' <br /> PUMP INSTALLATION /—/ PUMP REPAIR -/ PUMP REPLACEMENT )X--r I/ / _ <br /> DISTANCE TO NEAREST: SEPTIC 'TANK <br /> E SEWER_LINESPIT PRIV � <br /> Y � <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WEL _ PUBLIC DOMESTICOTWE <br /> LLL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ind usttial _ _ ___ - _Cable Tool � __ Dia^of Well_Excavation XN <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public <br /> Irrigation Driven Gauge of Casing <br /> I Gravel Pack ` Depth of Grout Seal <br /> Cathodic Protection Disposal Rotary Type of Grout <br /> .� �,' . Other �, Other Information <br /> Geophysical _ (� Surface Seal Installed By: <br /> PUMP INSTALLATION: -Contractor }CJ,[ Q <br /> 'Type of Pump H.P. / <br /> PUMP REPLACEMENT; - / State Work Done � <br /> PUMP .REPAIR: State Work Done <br /> F <br /> I � <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with fall 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 I <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 kn. wledge and belief. I WILL CALL FOR A GROUT INSPECTION J <br /> PRIOR TO GROUTjjf�G ANDA IN INSPgFj, _ <br /> SIGNED TITLE <br /> DRAW P T PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY ( DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE fx .�/ <br /> E H 1426 Rev. 1-74 3/76 2M <br />