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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- S/r71`57 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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/LOCATION2�2 -! Zi CENSUS TRACT <br /> Owner's Name -70 IV In. ��}^ ,� �� Phone <br /> Address } City <br /> Contractor's Name J,� , SLIZION SO W License #,a27�0;o Phone ;- T1 <br /> TYPE OF WORK (Check);—_NEW WELL /-7 DEEPEN '/_/ RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT 4 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 'ti 4, i ' CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable: Tool Dia."oF' Well Excavation <br /> Do.meStiC/private t Drilled Dia, of Well C_ asing_ <br /> Domestic/public : t Driven �' Gauge of Casing <br /> Irrigati�6n' ""`` I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal t Otherf Other Information <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION � Contractor <br /> - "k- Type of Pump { H.P. <br /> PUMP REPLACEMENT; .y State Work Lne it r—M ova- �G � ��O/,.�hJcS��f% Se�Z <br /> Y PUMP .REPAIR: T. ;'/// State Work Done <br /> Q <br /> ' DESTRUCTION OF WELL: Well Diameter l�-: fi 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 GR TING AND FINAL INSPECTION. <br /> SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED BY / DATE 5 -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II,GROUT INSPECTION PHAS_ III/)F;INAL INSPECTIO <br /> INSPECTION BYDATE ' INSPECTION BY DATE f f <br /> 1. <br /> 1177- 2M <br /> E H 1426 Rev. 1-74 <br />