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at <br /> J SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z_jL_5_ {' <br /> } <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /-a6-77 i <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 Ruleg and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -21 GJa Ii�w.PJ�c.rr� CENSUS TRACT <br /> �7 cy <br /> Owner's Name V!� � i � � � Phone / / `23 o <br /> Address P O. d City <br /> j <br /> Contractor's Name License #/(.237_3Phone 16( F I <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / RECONDITION /',DESTRUCTION /- <br /> PUMP INSTALLATION / / 7PUMP REPAIR /)Q PUMP REPLACEMENT /7 <br /> Other / / t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .r <br /> - -Industrial Cable Tool Dia. of Well Excavation W ti <br /> Domestic/private Drilled 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 r ..Sur-face._Seal. Installed By:__ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. s <br /> r <br /> PUMP REPLACEMENT: State Work Done <br /> v <br /> PUMP .REPAIR: State Work=Done:P P <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 kno ledge and belief. I WILL L FOR A GROUT INSPECTION , <br /> PRIOR TO GROUT AN "A FIN NSPECTION <br /> SIGNED TITLE ' <br /> 3 „ D W POT PLAN 'ON REVLRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY , DATE X- 3 7 7 <br /> ,ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / -Z/ 7 7 <br /> 3/7b 2M <br /> E H 1426 Rev. 1--74 <br />