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SAN JOAQIIIU .LOCAL HEALTH. DISTRICT <br /> -FOE 'OFFICE USE: ,,nom 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-ell's GCJ <br /> 777-1,16;0FA <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued ?-X',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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. 4 <br /> JOB ADDRESS/LOCATION �s Z(4Y1A.VP146 CENSUS TRACT <br /> Owner's Name P*Vj A�� � .��eZ'.v P Phone <br /> Address _ _ ,] /�..� City <br /> Contractor's Name . V _ .� License � M Phone �- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -'/ J RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INST TION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br />"DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL }MELD `� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEZ S CRIVATE DOMESTIC WELL 7��PUBLIC DOMESTIC WELL e <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �Q Domestic/private . Drilled Dia, of Well Casing <br /> "�— Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 92 r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> _TT . <br /> PUMP INSTALLATION: Contractor X <br /> , w2s <br /> Type of Pump ;t 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 /> F <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 /> 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 INSPECTI N <br /> PRIOR TOO GROUTING AND A FINAL INSPECT /I <br /> SIGNED LE <br /> . P C1 LAN`ON RE ERSE SIDE) <br /> FOR DOPARTMENT USE ONLY 0 <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE " <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P , JF NAL INSPECTION € <br /> INSPECTION BY DATE INSPECTION BY DATE { <br /> of GC'Y- <br /> E H 1426 Rev. 1=74 3/76 <br />