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SAN JOAQUIN LOCAL HEALTH. DISTRICT . <br /> j` FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton,,Calif. � <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77-z,3V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 18862 and the Rules and Regulations <br /> �fof� the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name /"a � �1f Q g ' 1 <br /> Phonev � `77 <br /> Address l Jrr- C"� <br /> CM <br /> Contractor's Name Licena� Pho <br /> _ _ i <br /> TYPE OF WORK (Check) : NEW WELL -DEEPEN /�/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK IU SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE PAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI!ZATIQNS <br /> --- Industrial Cable Tool . .. Dia. of Well Excavation <br /> ►/ Domestic/private Drilled ' Dia. of Well Casing <br /> Domestic/public Driven Gauge _of. Casing. <br /> / Aj . <br /> Irrigation_._ , ,,...: _ -- Gravel"Pack``' ;Depth of Grout Seal 0t <br /> Cathodic Protection �� Rotary - Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ; Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H'p. <br /> PUMP REPLACEMENT: /-State Work D <br /> PUMP REPAIR: "�_ / T/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br />--�-�- -.-- 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"tny 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 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE .1.2- -1 -,77 <br /> ADDITIONAL COMMENTS: ,��-3-? �✓�, ��._ <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATEA INSPECTION BY _.. DATE ;7-j79 <br /> E H 1426 Rav_ 7-7L W177 1•:9M <br />