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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-10.33f6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ) <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 10, ffj <br /> CENSUS TRACT <br /> Owner's NamePhone3 �/'-- 413 2 <br /> Address 2 q lrll City <br /> Contractor's Name 40 License #A,x,37.3 Phone 3( - -3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /-7 <br /> Other / J <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 9 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump — 7"_ H.P. 1!� <br /> PUMP REPLACEMENT / / State Work Done - <br /> PUMP .REPAIR: _4S�r State Work Done- <br /> .4�-" <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 GROUTIA MD A.ZPAL INSPE TION. <br /> SIGNED TITLE <br /> RAW POT PLAN ON REVERSE SIDE) '' _'� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COM ENTS: <br /> PHASE II GROUT INSPECTIOIVv PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE IX-ee-7'7 <br /> E H 1426 Rev. 1--74 <br /> 3/76 2M <br />