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v + <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WEE'I ONSTRUCTION OR PUMP PERMIT Permit No. D 1v <br /> 77- 1-14-3 P <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued) <br /> (Complete In Triplicate) <br /> Application is hereby trade t{o the San Joaquin Local Health District for a permit to construct <br /> ti 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 /> ;1 <br /> JOB ADDRESS/ ir /r�C1211L r CENSUS TRACT <br /> fOwners Name k1r, L Phone <br /> Address ! City <br /> Contractor's Name M19 2911 �? S f��i .j� LicensePhone, JZr �✓� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 4y DEEPEN / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT <br /> A <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSIELD _ CESSPOOL/SPE LIC DOMESTIC <br /> .- PROPERTY LINERIVATE DOMESTIC WEL UB <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <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 Sealer <br /> Cathodic Protection 1= Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed B <br /> y PUMP INSTALLATION: Contractor,, Y1 rz2. 1? -C \ <br /> Type of Puinp _ H.P. <br /> r. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: :. _ /j /- _State Work Done <br /> t <br /> DES-TRUCTION OF WELL: We11 Diameter Approximate Depth <br /> 7. '' Describe Material and Procedure <br /> I hereby agree °to comply with alllaws 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 c"f my wbrk-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 GROUTING AND A FINAL INSPECT E -� Z /` zG <br /> SIGNED (/(� <br /> PtbTf PLAN' 1 E`STS iISE) <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION <br /> ACCEPTED-DATE - <br /> ADDITIONAL <br /> ATE .ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE 'III/FINAL INSPECTION <br /> INSPECTION BY 1 DATE ter- V,7-7 7_ INSPECTION BY DATE r-- 7 --77 <br /> . � 3/7b 2M <br /> E H 1426 Rev. 1-74 <br />