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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF ICE US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- �6�/° <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 6--3/'77 <br /> (Complete In Triplicate) <br /> Application is hereby made tokthe 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 Rules and Regulations of the San Joaquin Local Health District. <br /> 11 <br /> JOB AT DRE��LOCAJR TION CENSUS TRACT <br /> Owner's Name m S fi Phone i <br /> Address / B <br /> City�a.S I6�� Os . <br /> Contractor's Name - <br /> License #/j <br /> 7 j_At one <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENRECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION <br /> PUMP REPAIR / PUMP REPLACEMENT /� <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 W <br /> INTENDED. USE TYPE OF WELL �,, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia., of Well Excavation <br /> Domestic/private _ Drilled - <br /> Dia, of Well Casing �' <br /> Domestic/public Driven Gauge of Casing L <br /> K Irrigation .- j Gravel'Pack S Depth 'of Grout Seal <br />� Cathodic Protection Rotary t Type of Grout <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump r . <br /> PUMP REPLACEMENT: / / . State Work Done , <br /> - - � <br /> a <br /> PUMP .REPAIR: f)c/ State Work Done ` .� — � - <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 /> r <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 <br /> PRIOR TO GROUTING AND A FINAL INSPE N. , <br /> TITLE ,`: <br /> SIGNED <br /> ` - D PL T PLAN ON ARSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ DATE7 <br /> APPLICATION ACCEPTED BY _Z,-�gz <br /> { ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY DATE/ -J - 7'7 <br /> INSPECTION BY _ <br /> 1177 2M <br />