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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.72YZlj�, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-1-77 <br /> (Complete <br /> 1/- <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/.land the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ( Phone <br /> Address ' <br /> 0 r� /Wn city,,57-Pckon <br /> Contractor's Name License 4 4�246Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ 7 <br /> _/ RECONDITION /� DESTRUCTION / <br /> PUMP INSTALLATION/ PUMP REPAIR /_/ PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK-17� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Z3 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE APRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven 'Gauge of Casing (,d <br /> Irrigation Gravel Pack Depth of Grout Seal `71 <br /> Cathodic Protection Rotary Type of Grout 1�C- <br /> Disposal Other Other Information �� <br /> Geophysical Surface Seal Installed By: <br /> PUMP .INSTALLATION: Contractor / �~ <br /> Type of Pump Je- 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 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 puttingthe..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 /> PRIOR TO GROUTING AND A FINa INSPECTION. <br /> SIGNED TITLE., <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE .I <br /> APPLICATION ACCEPTED BY _ _ C�'� -------- DATE <br /> ADDITIONAL COMMENTS:�EUE &I GROUT INSPECTION P /FINAL INSPEC ON - <br /> INSPECTION BY DATE INSPECTION BY DATE .L �'" 1-2 <br /> E H 1426. Rev. 1X74 _. . 1177 2M <br /> -- _. , <br />