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�SAN_ JOAQUIN LOCAL HEALTH DISTRICT <br /> �4 <br /> FOR OFF.IC .-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 0 Telephone: (209) 466-6781 �. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 hereinl4described. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 1862' and �he Rules and Regulations of the San .Joaquin Local Health District. <br />,JOB` ADDRESS'/LOCATION IJ '-- E S� N CENSUS TRACT <br /> k <br /> Phone 239-7502 <br /> Owner's 'Name <br /> t <br /> /+' /9!/P ✓ S dr1 City <br /> Address <br /> Contractor's Name /81f.�/d��f 1Q �' /N�• __ License # Phone - <br /> TYPE OF WORK (Check) : NEW WELL /> DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION _0 PUMP REPAIR/ / PUMP REPLACEMENT /? , <br /> Other <br /> A <br /> DISTANCE TO NEAREST: SEPTIC .TANK Q SEWER LIMES PIT PRIVY <br /> SEWAGE bISPOSAL FIELD--,140 CESSPOOL/SEEPAGE PIT7tso OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ /�z`/ _ �4 <br /> �t <br /> Domestic/private E Drilled Dia. of Well Casing [ - <br /> Driven Gauge of Casing " <br /> Domestic/public g (U � <br /> ^fir Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . i X Rotary Type of Grout Co � -4ry�6 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B &O-AL- <br /> PUMP INSTALLATION: Contractor ' <br /> H.P. <br /> Type of Pump (14,6,lAl S't1� S G _ <br /> PUMP kEPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State WoDone <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws-and regvla ions 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 `I <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 <br /> PRIOR TO GROU NG AND A FjaAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PL TPLAN 'ON RE FRSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE IDATE 3 <br /> APPLICATION ACCEPTED BY iu <br /> ADDITIONAL COMMENTS: <br /> P I RO T INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,7 <br /> S64 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />