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F <br /> 6 <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE U9t,` 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone ; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-1-fl& <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquini� <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. ` <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name . U t s_�_D CC Phone 6S--6 <br /> Address <br /> Citrc:)ck <br /> Cd c,u <br /> Contractor's Name Al E�Z_ License # Phone ' <br /> TYPE OF.,WORK (Check) : NEW WELL / / DEEP ,/ / RECONDITION /_/ DESTRUCTION /_ <br /> I <br /> PUMP INSTALLATION 1X1_ PUMP REPAIR / / PUMP REPLACEMENT /-7. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES_4200 PIT-PRIVY <br /> r SEWAGE DISPOSA IELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINERIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELL � E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4}.: <br /> Industrial Cable Tool Dia, of Well Excavation Q <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 OtherInformation <br /> Geophysical . Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> rType of Pump _L01E_q leffllyE H.P. � f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> DES T'RUCTION OF WELL: Well 'Diameter <br /> Approximate .Dep th <br /> Describe Material and Procedure ' r' -- <br /> t <br /> I herebyl.agree to comply with all laws and regulations .ofrthe 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 beforeN.putting. the. well in.,.use. - The above <br /> information is` true tofthe best of my knowledge and"'bed.ief. I WILL ' -FORCALA GROUT INSPECTION i <br /> PRIOR TO GROUTING AND A-FI-NAJ, INSPECTION. -, <br /> SIGNED , TITLE LcJ'/VE i <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ^' b <br /> f fFOR DEPARTMENT -USE ONLY ti <br /> PHASE I _ <br /> APPLICATION ACCEPTED -BY_­� DATE 9-20- <br /> ADDITIONAL COMMENTS_:__ - r � <br /> PHASE II GROUT INSPECTION _ f PHAS II/F NAL INSPECTIODT <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H. 1426 _ - . r 2M <br />