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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: `N/ 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> . Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- /.;7-0O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 9-30-7 <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. <br /> JOB ADDRESS/LOCATION "7$ CENSUS TRACT <br /> Owner's Name j Phone <br /> Address .7 �-e cw 0( City 1-.04 ! - - <br /> Contractor's Name V&rt r tg fgL p v r+a 'd 4 S'i-,p 021-!X_1 .r License # Abfl,61 Phone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK-'>30 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 /> ,ems Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor VNtvPte *Y1 <br /> Type of Pump `TZ ,• H.P. 7Z-:�.Ej <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 GROUTIN AND A .FINAL INSPECTION. <br /> SIGNED �,�, TITLE. <br /> Z�— <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE Ie <br /> APPLICATION ACCEPTED BY �d - DATE 7� Z <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE I/ -7-- '; - 7 <br /> 6'77 . 2M <br /> E H 1426 Rev- , l-74 _ -_- <br />