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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ ,7.7 96s <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. I <br /> S THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued i- Z-77 <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 SJ ��(� ,�� CENSUS TRACT <br /> Owner's NameA6) C Phone d: <br /> Addressor ,�' City <br /> Contra -3 /z tor's� Name. OfLicense <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITTON /—/- DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private erBrilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L__R-otary Type. of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: CZ �r <br /> PUMP INSTALLATION: --- <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT /7 State Work Done <br /> PUMP .REPA / / State Work Done <br /> --To 13� P�.c�� -'e-17 AN b Q r <br /> D STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material nd 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 G INGANP A FINkk INSPECTION. _ J <br /> SIGNED TITLE `I'-' <br /> 7-71 <br /> (DRAW T PLAN ON RE FRSE.-SIDE) -•..�: <br /> FOR DEPARTMENT USE -ONL *V7I <br /> PHASE I <br /> APPLICATION ACCEPTED BY l/v ��_ °`""^DATE.... <br /> ADDITIONAL COMMENT YUAnPII G OUT INSPECTION PHAS III/F NAL INSPECTION <br /> INSPECTION BYW DATE - - 7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 � P , �!' "` 3/76 2M <br /> ,. ,. <br />