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- a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- Altt4d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /L ! � <br /> _ _7J I <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �yS��D Gtr f Jwy .2, - CENSUS TRA <br /> Owner's Name �/Q1 L /i Phone 36c�1 /G <br /> AddressCit <br /> y 0607.0' y 1 <br /> Contractor's Name l .License g?YY?? Phone,r/f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /_7 DESTRUCTION /—j I <br /> PUMP INSTALLATION & PUMP REPAIR / 7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 14M , SEWER LINES PIT PRIVY y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - -PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial �_ Cable Tool Dia, of ;Well Excavation % � I <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /O Gam , <br /> _ Irrigation Gravel Pack Depth of Grout Seal l <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: / /7 Cr-eSS <br /> PUMP INSTALLATION: Contractor Q '?y/ (5:,-pSjs' <br /> Type of Pump Tu ,-Ai.v-P H.P. $ <br /> PUMP REPLACEMENT:. ,`. ../ / State Work Done' <br /> PUMP REPAIRS _ ./% 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 thebestof- myknowledge-andbelief. I WILL- CALLFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN5 A FINAL NSPEjCTION. <br /> SIGNED ry_.,, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f/lam DATE <br /> E H 1425 -Rev. 1-74 - -- - 4/75 2M <br />