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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. 7;7- ,Vo y, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 'I-A---27 <br /> (Complete In Triplicate) <br /> Application is Aereby made 'to the San Joaquin Local Health District for a permit t6 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 /> 27 <br /> JOB ADD SSS/0 ATION6 S, J aF -relr,* tet_ Rd of i/z.CENSUS TRACT <br /> Owner's Name e, Phone ' 3 6 2 <br /> Address O City �,Ci r` <br /> Contractor's NameSO4 92 UA-42 c Licensekil <br /> Phone .¢ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN / / RECONDITION /—/ DESTRUCTION /-J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT //7— <br /> Other <br /> DISTANCE TO NEAREST: - SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER z" k <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool :Dia, 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 oflGrout , <br />—Disposal. Other Other Information <br /> k <br /> Geophysical Surface_ Seal` Installed( By: _ <br /> PUMP INSTALLATION: Contractor <br /> TYPe of Pump /� r P H.P. ) <br /> PUMP REPLACEMENT: / / State Work Done r �S, _,• YB &;,o-s <br /> _ r' r <br /> L <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depths <br /> Describe Material and Procedure' Y <br /> 4 _ <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 'FIFTEEi4 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-CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FJINAL INSPECTION. <br /> SIGNED TITLEs <br /> ,47 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT-ED BY <br /> DATE , <br /> h l5 #, <br /> ADDITIONAL COMMENTS: . i <br /> --— - --PHASE -11---GROUT INSPECTION- PHASE-III/FINAL INSPECTION- <br /> INSPECTION <br /> NSPECTION INSPECTION BY 441A DATE INSPECTION BY DATE <br />�E H 1426 Rev. 1-74 ; 1/77 " 2M <br />