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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFF'ItE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-Zr-i y/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�-- 7_ 77 <br /> F (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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a - mi, auQ CENSUS TRACT <br /> Owner's Name / Phone <br /> Address <br /> City ' <br /> Contractor's Name t' License <br /> z . . 4 J Phone =;z <br /> �• yF <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> / / PUMP REPLACEMENT /� f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 WER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ILD, . .,..CESSPOOL/SEEPAGE• PIT-, r <br /> �: OTHER. ,�/Q` <br /> PROPERTY LINE_- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool,` Dia. of Well Excavation 7/ i <br /> Domestic/private Drilled ' Dia, of Well Casing <br /> Domestic/public - t Driven Gauge of Casing t � <br /> Irrigation Gravel 'Pack Depth of Grout Seal A <br /> NZ <br /> Cathodic Protection RotAr A <br /> ,Y Type of Grout m � <br /> Disposal Other <br /> l M Other Information —"-' <br /> Geophysical " ` - <br /> f' Surface Seal Installed By: ki <br /> PUMP INSTALLATION: Contractor. e C <br /> Type of P}mp H.P. <br /> PUMP-- REPLACEMENT: / / Stated Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF. WELL: Well Dia titer ' <br /> Approximate Depth <br /> ;Describe Material and Procedure T- ` �" <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health bisirict I <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 CALL FOR A GROUT INSPECTION 1 <br />'RIOR TO GROUTING ANDA FINAL INSPECTION. J <br /> SIGNED Cl ZZ, <br /> 6 TITLE <br /> DRAW PLOT PLAN ON VERSE SIDE) • - <br />?RASE I ----- <br /> FOR XPARTMENT USE ONLY <br />?APPLICATION ACCEPTED BY DATE <br /> 9'/Z X <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA •TI ,F'IN INSPE§T16N <br /> INSPECTION BY DATE INSPECTION BY t DATE <br /> E H 1426 Rev. 1-74 1177• 2M <br />