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A (7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (2.09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 77-"��1° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .)_90-7,7(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 /> F County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ �.Cf � CENSUS TRACT <br /> Owner's Name Phone <br /> " Address - of City <br /> Contractor's Name oc� r �v+✓N T - License Phone . <br /> TYPE OF WORK (Check) : NEW WELL ? DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION .� FUM!' REPAIR /—/""'�I'UI'?P`REPLACEMENT /� <br /> Other <br /> DISTANCE TO EAREST: SEPTIC TANKS SE PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOW SEEPAGE PIT ... " OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELL.3, PUBLIC DOMESTIC WELL <br /> INTENDED USE - aa TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled -` Dia. of Well. Casing 6 '� <br /> Domestic/public Driven Gauge of Casing / z- �• <br /> Irrigation Gravel Pack Depth of Grout Seal fQ <br /> Cathodic Protecttion �_ Rotary Type` of Grout <br /> Disposal. Other Other Information <br /> ff Geophysical Surface=Seal Installed By; <br /> C - <br /> �4e et <br /> PUMP INSTALLATION: Contactor <br /> ' # Type4of Pump , H.P. <br /> PUMP REPLACEMENT: / / ?State Work Done <br /> PUMP .REPAIR: / / -State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> w 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 REPOR he well and notify them before putting the -well in use. The above <br /> information is e to the best of my-knowledge and belief. I WILL CALL F2AA GROUT INSPEC I <br /> PRIOR TO GRO INSF ION. <br /> SIGNED TITLE <br /> 2?!. DRAW SOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y DATE <br /> ADDITIONAL COMMENTS: <br /> - PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY -- DATE INSPECTION BX _ DATE <br /> 5. � 3/76 <br /> E H 1426 Rev. 1-74 <br />