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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ff 771,r) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 77-140 y1p <br /> /�� <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/L"MWgX(. �� Q.sC CENSUS TRACT <br /> Owner's Name �� f`d�7 Phone <br /> Address _ City <br /> Contractor's Name . <br /> License iV��Phonel P <br /> i <br /> ti i <br /> TYPE OF WORK (Check).: NEW WELL DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR '/—/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . 0-t- SEWER INEST � PIT PRIVY <br /> SEWAGE DISPOS PE -+--EESSPOOL/SEEPAGE PIT ] t-DTHER <br /> PROPERTY LINF�PRIVATE DOMESTIC WELL "ow PUBLIC DOMESTIC WELL Q0 , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L� <br /> Industrial Cable Tool Dia. of Well Excavation p1 <br /> Domestic/private - Drilled Dia. of Well Casing f/ <br /> XDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Jic Rotary Type of Grout j�e_, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ?- <br /> Type-of Pump, N., H.P. <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 theSanJoaquin 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 potting the.wellin use.. The above <br /> information is true to the best of my'knowledge and belief. I WILLCALLFOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI A >' L <br /> SIGNED —:PA <br /> ITLE ` r <br /> "- W PLOT P AN ON REVERSE SIDE) <br /> FOR DEP TMENT USE'ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ � ,.' 1'� DATE z <br /> am <br /> ADDITIONAL COMMENTS: ; +�_ <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE &l ,INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ` 1177 2M <br />