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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS!'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ,7 _ <br /> Telephone: (209) 466-6781 P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `7 7-� <br /> THIS PERMIT EXPIRES 1 REAR FROM DATE ISSUED Date Issued /i'77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sari�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 Joaquin Local Health District. <br /> e <br /> JOB ADDRESS/LOCATION S CENSUS TRACT <br /> Owner's Name 14Z o5�S°e Phone <br /> Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /_7 RECONDITION [T DESTRUCTION <br /> PUMP INSTALLATION )K/ PUMP REPAIR 1_7-PUMP REPLAC <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Cathodic Protection Rotary i Type of Grout <br /> Disposal Other I Other Information <br /> Geophysical _ " ` - Surface Seal Installed By. <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump , H.P. <br /> _ . <br /> PUMP REPLACEMENT: / J State Work �Done <br /> PUMP *.REPAIR: <br /> / State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter ? Approximate Depth <br /> fDescr be Material acid Procedure <br /> I hereby agree to comply w th 1 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 /> f information is true to the-best of my.knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TOG U TNG AND FINAL INSPECTION. <br /> E SIGNED 977 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY4 DATE '' 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION P E IIT NAL INSPECTION <br /> k INSPECTION BY DATE <br /> INSPECTION BY DATR# <br /> 1-74 2M <br /> E H 1426 Rev. 1-74 <br />