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/ SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> FOR <br /> OFFICE 'USE: j/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 } <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-a wo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-W-77 <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 Joaqu Local Health,District. <br /> JOB ADDRESS/LOCATION ✓ �d-� � � CCEENJSUS TRACT <br /> t ' <br /> Owner's NameG��-Q,�� Phone <br /> Address ' City ,. ,...,., <br /> Contracto 's Name License ;� a� Phone <br /> Al <br /> x <br /> TYPE OF WORK (Check): NEW WELL'/-7 DEEPEN / / RECONDITION / DESTRUCTION �f <br /> PUMP INSTALLATION.//:PUMP REPAIR /7 PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST:,,ySEPTIC TANK SEWER EINES PIT PRIVY <br /> SEWAGk DISPOSAL FIELD CLSSPOOL/SEEPAGE PIT ()THBR \ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . �. <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casingj. <br /> Domestic/gublic -.Driven . Gauge cif--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 ec0 <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 FIMIN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distxiet a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The �ebdve' - <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT IdSPECTI <br /> PRIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W.: PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> „t <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL 100MMTS: <br /> PHASE II GROUT INSPECTION PHASE IjjjFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYI,,61 DATE <br /> V76 2 <br /> E H 1426 Rev. 1-74 } 4 <br />