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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. All� <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-/SiE/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-_23-77 <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 W00 <br /> 69W 0,0, SR_r 0V CENSUS TRACT <br /> Owner's Name Phone <br /> Address Td LO R.0 City <br /> Contractor's Name z( 0x11(, /W, License # ©Z Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /�EPEN %% RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR/—/ PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK "-,F- 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 a Tool Dia. of Well Excavation <br /> �mestic/private Drilled Dia, of Well Casing ,`r <br /> - - -- <br /> Domestic public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Mary Type of Grout Le�.-t <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .....H.P. <br /> ' - <br /> eU441_ 001 <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 <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 GROUTINGAND FINAL SPE ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEP49TIMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE &_l 2 7j4 <br /> ADDITIONAL COMMENTS: Vj <br /> PHASE II GROUT. INSPECTION PHASE III/FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 11177 _ 2M <br />