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SAN JOAQUIN�LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: � 1601 E. Hftzelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77rz 0_&-) <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 7® f G C CENSUS TRACT <br /> Owner's Name [ E�- V-9Phone <br /> Address &C City —C 7 A- <br /> Contractor's Name �L.n License-V t ��Ah 44e/1-5'1r/26 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /Y RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / UMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL __ PUBLIC DOMESTIC WELL r� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _X Cable Tool Dia, of Well Excavation <br /> _ Domestic/private Drilled Dia, of Well Casing l <br /> Domestic/public Driven Gauge of Casing Im <br /> mmm _ <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout 5�FA/C-/ CC'AgGj%j <br /> .Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: n <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �, 7 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 putting the well in use. The above <br /> information is tru to the best of my knowledge and belief. I WILL CALL FOR A GROUT NSPECTTON <br /> PRIOR TO WUTIA A FIba INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY E� DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E IN INSPECTI N <br />,-INSPECTION BY DATE '7 '� INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 _ x- ek ey✓xt�_` <br />