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C� 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 N _o. 77-3,F8W <br /> 77-14 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dr� Da:sued <br /> #tconstruct(Complete In Triplicate)Application is hereby made to the San Joaquin Local Health District for a permit <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 - ' (vim CENSUS TRACT <br /> Owner's Name Phone 172 <br /> Address - <br /> city <br /> Contractor's Name u t/ License IV6.2-30 Phone3-t-J J� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION J5C/' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7,1 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation -40-71,f� <br /> -A Domestic/private Drilled Dia. of Well Casing tf, <br /> Domestic/public Driven Gauge of Casing, 1.2- "1 <br /> Irrigation Gravel Pack Depth of Grout Seal �'a , <br /> Cathodic Protection x -Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELD: - '- -Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure a <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 kn9tvledge and belief. I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND AZINAL INSPECT <br /> SIGNED TITLE <br /> UTW PLAN 'ON M fitSESIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ( -'-- <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL -COMMENTS: <br /> PHASE II GROUT IIQSPECTIO HASE I Y NAL INSPECTION <br /> INSPECTION BY DATE � _ ' SPE TION- Y DATE 3 77 <br /> �rrn� 23 �Z 4� S 2df e4r <br /> L J 7b ., <br /> E H. 1426 Rev. 1,74 S~er ,. 2r' r�.,�/ l�S. �3Yiv�-e tan an/tao*! /.: � sA,f <br />