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F SAN JOAQUIN LOCAL HEALTH. DISTRICT Psq� <br /> 4 FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> GTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per t No. 77-.2 70 z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-7/_�> <br /> rr (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. 1$62 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �i/e CENSUS TRACT <br /> a <br /> Owner's Name � ��_ <br /> Phone <br /> Address `�� /i. ule, C City <br /> Contractor's Name Howt (, tv= +9 i Q License #jW&ITyAPhone's��!'L <br /> TYPE OF WORK (Check) : NEW WELL '/y DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION j? PUMP REPAIR REPLACEMENT /_ <br /> Other / / <br /> ISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS�IFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINLW? PRIVATE DOMESTIC WELL7:fi- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled _ Dia. of Well Casing <br /> ,Domestic/public - ...... _ Driven. Gauge ofCasing <br /> Irrigation Gravel Pack Depth of�Grout-Seal � \> <br /> Cathodic•Protection Rotary Type of Grout `l <br /> Disposal Other, Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor-, �` : d'• <br /> Type of Pump H.P. AKO <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / ,State Work Done b <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 true to the best of. my knowledge and belief. I WILL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G ANDIN ECT ION. <br /> SIGNS TITLE <br /> Ni-WD W PL T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> �._ PHASE I <br /> APPLICATION ACCEPTED BY DATE 3" 1-1 <br /> ADDITIONAL COMMENTS: <br /> { <br /> PHASE.IR UT INSPECTION PHASE, /FINA INSPECTION <br /> r INSPECTION BYZVI <br /> DATE INSPECTION BY DATE <br /> ' � PP 376 ;2M <br /> �� E H1426 Rev. 1-74 �.a- �►.t, - . <br />