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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. 77571,4Ld <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,, y_?7 <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ® Q ,01. CENSUS TRACT <br /> Owner's Name �i � � �f _ Phone <br /> o� c� <br /> Address _0? S-l ! S- W C1 City 0 <br /> Contractor's Name �'j� Qf I ' ` License 9�6s-/*Phon / <br /> L <br /> TYPE OF WORK (Check) : NEW WELL/L-/'­�EEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /SUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGt PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC 'DOMESTIC WELL , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4--Cable Tool Dia. of Well Excavation <br /> L-13-6mestic/private Drilled ' Dia, of Well--Casing` . <br /> - Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other k0ther Information" <br /> Geophysical b / Surface Seal Installed_ By;_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 <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 GROUT G MD A FINAL WSKCTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN 'ON REVERS E SIDE <br /> FOR DEPARTMENT USE--ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � L. t 3/76 2M <br /> E H 1426 Rev. 1-74 / <br />