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• .t ,4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO :OFFICE USE: I/" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-g$5 v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 LS CENSUS TRACT <br /> �--� <br /> Owner's Name � � Z-L�a_ Phone <br /> Address City <br /> Contracto 's Name Lice e # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %/ :RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / — — <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 , SEWER LINES 761 PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 <br /> 1/Domestic/private i—ITrilled Dia. of Well Casing <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ~� <br /> PUMP .REPAIR: „Work <br /> S, State Work Done <br /> LCL D G.1 F�c.L 7d ,dam � L�NDo Al P 6 V o wry 2 w <br /> D TRUCTION OF WELL: ell Diam�et�ex .�., _ „ , fAgftoximate Depth <br /> Describe Materiatand�Procedure 0-V7 0.4-- S-41 l// <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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN AND A FINAL INSPECTION. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> EOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY A ���"A�E -77/`777 <br /> ADDITIONAL COMMENTS: <br /> PtLAM111—GROUW INSPECTION PHASE, III/FINAL INSPECTION <br /> INSPECTION BY DATE _ 77 INSPECTION BY DATE 7 <br /> 'P4 - 1'2- Al <br /> _�E H 1426 Rev. 1-74 <br />