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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. 7 7_��d <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �y7 2Z <br /> 77-7-,-P7 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ; -;—z <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 <br /> rRules and Regulations of the San Joaquin Local Health District. <br /> ,SOB ADDRESS/LOCATION „�7��`7 /J� � ��Le �y� CENSUS TRACT <br /> Owner's Name Phone <br /> Address �� / /��C� c G -- - ----- City a psi <br /> Contractor's Name Ccs_ s r G License VpV Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? s <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ZOO CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/-D PRIVATE DOMESTIC WELL _PUBLIC DOMESTIC WELL <br /> INTENDED USE µ TYPE OF WELL _ _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 'T Dia. of Well Excavation 0 r <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. of, Casing <2 .1,6 1,6o 7771C <br /> Irrigation Gravel Pack Depth of Grout Seal -3�Q' [� <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed By. e <br /> PUMP INSTALLATION: Contractor 42 <br /> 4 <br /> i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F-7 State Work Done <br /> PUMP .REPAIR: 4. <br /> °/ / State Work Done <br /> DES4RUCTION OF WELL: Well Diameter Approximate Depth <br /> ocr— <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 a ell and notify them before putting the .well in use. The above <br /> information is truVfo the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU IO401, <br /> SIGNED TITLE <br /> DRAW PL T PLAN 'ON RE ICRSE SIDE <br /> FOR 'NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED, Y � � DATE <br /> ADDITIONAL COMMENTS: <br /> P E G OUT INSP%tTIOW PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE -S-? <br /> 3/76 <br /> E H 1426 Rev. 1-74 C . <br /> �_ . . <br />