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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 0-6 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-227 <br /> 1 (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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION 1 / l 6, AS`Sl 6A &ASE _-. — CENSUS TRACT <br /> � J � <br /> Owner's Name cj'Q �t i Phone «.: "7 <br /> Address 14 / <br /> City r ?V <br /> of <br /> Contractor's Name ct is <br /> License #'1 ` i6 Phone Mc V <br /> cTYPE OF WORK (Check) : NEW. WELL r/ / DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /C.- <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 it <br /> Geophysical Surface Seal Installed By: <br /> ( PUMP INSTALLATION: Contractor v <br /> Type,of Pump (111 m.e c H.P. <br /> r <br /> PUMP REPLACEMENT / / State Work Dane <br /> 'Pump- _ % / State ark Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure C <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 /> jafter completion of my work on a new well, I will furnish the San Joaquin Local Health District s <br /> ' WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> Finformation is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 4PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> : SIGNED TITLE l <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> DATE T 22 <br /> APPLICATION ACCEPTED BY <br /> 4ADDITIONAL COMMENTS: <br /> k PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY / DATE � _ <br /> 1177 2M <br /> F. H 1426 Rev. 1-74 - <br />