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F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 y3f <br /> k THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued i; 3- 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 incompliance With San Joaquis <br /> , County Ordinance No., 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T" rte/ �T�` o S r T-i4L, CENSUS. TRACT <br /> Owner's Name Phone ' 9y ' '>37, <br /> Address <br /> S` v �� �- ' .� it I N <br /> k <br /> Contractor's Name , /2 �/ /��Ca //d�� gC`/YU,O Lic se ,# Phone kaD3 <br /> V <br /> r - <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN '/-7 RECONDITION f7 DESTRUCTION /f <br /> PUMP INSTALLATION 7 PUMP REPAIR /T-T—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (i <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 3, -,CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Did -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 Seal. <br /> Cathodic Protection Rotary -, . Type of Grout.. <br /> Disposal Other X41-'T-Other information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION:' Contractor <br /> . Type-of Pump ���.. �- �T w._ - - H.P. _:%5- <br /> PUMP <br /> 5`PUMP REPLACEMENT: y/ / S tate Work Done <br /> PUMP .REPAIR: .. /�f State Work Done <br /> fRUCTION 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 CAL OR,A-GROUT INSPECTION <br /> PRIOR TO GROUTING 'AN N NSPECTION. <br /> SIGNED TITLE --� <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I z <br /> APPLICATION ACCEPTED BY DATE ' S'I3'17 <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION v PHASE TTI NAL INSPECTIO, <br /> ;. INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> r' <br />