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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 ,E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1�3I-77 k <br /> (Complete In Triplicate) <br /> 4 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. lj <br /> JOB ADDRESS/LOCATION ] CENSUS TRACT ; <br /> t <br /> Owner's Name " Phone <br /> Address all 01ty City <br /> Contractor's Name / ,( 9 ,C.l r License # d, Phone <br />'�' r -�..-.,.µ _:1.�c -ter--x -- _ - _ _��� ._-.=fir-'t=�---c-•_ - - -�,--"-t'��..�� T- ._ - .. ._ .-,- - .. - ��I <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PliMP 'INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> 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 Ms <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing i <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- - Q, ,Pi w H.P. f <br /> PUMP REPLACEMENT: ' / / State Work Donei <br /> =PUMP'-REPAIR: _- -!-/7/­'State-Work- Done <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{' I <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 GROUTING AND A FINAL INSPECTION. 4 <br /> SIGNEDTITLE <br /> (DFAW PLT LAN `ON REVERSE SIDE) I: . . <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE I �l <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE i GROUT NSPECTION <br /> _ PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H2 , 3/76 I� <br />- I4 b Rev.. -1--74 _ <br />