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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 No. 77-_7_2&) <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/LOC ION � o ,cA4ttz- CENSUS TRACT <br /> Owner's Na d �' Phone .�33 <br /> Address Cit r' <br /> z�_A�2,tw <br /> Contractor's Name License # Phone <br /> i <br /> F <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other44 <br /> / I <br /> DISTANCE TO NEAREST: SEPTIC TANK l EWER LINES PIT PRIVY <br /> SEWAGE DISPOS IELD 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casingi <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information 7 <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: E7 State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Z4Approximate DepthU <br /> Describe Iat rial nd ocedure <br /> I hereby agree to comply with 4211 laws and regulations of a San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS j <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 /> informati s true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIG ING FI SPE <br /> SIGND TITLE + <br /> (DRA - PLOT' PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Y)D /r75p:7C fzoh <br /> 3/76 <br /> E 14 1426 Rev. '1-74 .3 128 <br />