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A*" s <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v Telephone: (209) 466-6781 -7>- .17FP <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77-.262W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-y1- 7 7 r <br /> r (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 ',s �. CENSUS TRACT <br /> Owner's Name 11agj. Phone f�/�"f <br /> Address City r <br /> Contractor's Name License Phone S — 7 <br /> `i <br /> i <br /> TYPE OF WORK (Check) : 'NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION , PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD 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 /,7— <br /> Domestic/private a Drilled Dia. of Well Casing _ 42 _• <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal O `' <br /> 'cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information .. w _ <br /> _ - f <br /> Geophysical Surface Seal Installed By; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: f / State Work Done w <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 k <br /> WELL DRILLERS REPORT e well and notify them before putting the well in use. The above <br /> information is t u to the bestm. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR INSPE IO <br /> SIGNED TITLE <br /> J,?' T' PLAN ON RE ELSE SI ) <br /> FOR DEPARTMENT USE ONLY rr <br /> PHASE I ,e► I <br /> APPLICATION ACCEPTED BY CQnSL DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION r <br /> INSPECTION BY DATE -� - 2 7 INSPECTION BY DATE • 117 -7,7 <br /> E H 1426 Rev. -I-74 <br /> 3/76 2M <br />