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_ �k5ilp �� 7� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> c <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-f/3i% <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x_/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 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 C 6 7 AfQ YL o..raL 74e, CENSUS TRACT <br /> Owner's Name r- ,� rS a S Phone <br /> F <br /> AddressR4-0-14-0 City <br /> Contractor's Name License hone •y . G 74 <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN / / RECONDITION / / DESTRUCTION /7 ! <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other / J <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation COT3 <br /> Domestic/private Drilled Dia. of Well Casing -Ij <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 Other Information # <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor et <br /> Type of Pump H.P. 00, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> F <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 wellin use. The above j <br /> information is true to the best of�-myhowled and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G 0 TING AND A FINAL INS ECT•�l <br /> SIGNED TLE �f e <br /> (DEM PLO MORN REV E SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 -x' "71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY AzDATE 7- 1 '27 <br /> E H 1426 Rev. 1-74 1177 _ 2M } <br />