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�y� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE "' 0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zip <br /> 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued2-27 <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 /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1$62 and the Rules and Regu <br /> JOB ADDRESS}�BN �oZ71e_ "' � CENSUS TRACT <br /> Phone <br /> Owner s Name i <br /> 11 <br /> City <br /> Address <br /> License <br /> Contractor s NameIn VASCG / 5 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION_/ / DESTRUCTION 1_7 <br /> PUMP INSTALLATION - PUMP REPAIR I I PUMP REPLACEMENT. l- <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other '_ Other Information �] <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> pescribe 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 <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 F 04 A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ITLE <br /> SIGNED <br /> W P T P ON RE FRSE SIDE <br /> FOR DE TMENT USE ONLY <br /> PHASE I DATE � 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p E / NAL INSPECTI <br /> PHASE II GROUT INSPECTION DATE J <br /> INSPECTION BY DATE 7 INSPECTION BY <br /> 3/76 2m <br /> -74 <br /> E H 1426 Rev. 1 <br />