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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. HazeltonAve. , Stockton, Calif. <br /> Telephone: j (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z7 7 9�r p <br /> THIS PERMIT EXPIRES 1 YEARi�FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ©S-,s 3�-l�- <br /> Application is hereby made to the San Joa.quiA 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 /> .JOB 'ADDRESS/LOCATION C1Q4f/4 fo� �i�z 'iii" ' 7-er/'2 G. -- CENSUS TRACT <br /> Owner's Name y r- O� { !] Phone <br /> �p <br /> Address <br /> D /5�4 7/ c. _-�-_. .:� city <br /> Contractors Name , <br /> License # d °fib/ Phone <br /> 777 �S{ <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/ J RECONDITION /_7 DESTRUCTION /7 <br /> PUMP IN,S�TALLATION / /` PUMP REPAIR '/ / PUMP REPLACEMENT �� 'J <br /> Other �.n __ �6 Llli�'� cu��y✓rt — G'l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSAL FIELD !If CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT, <br /> INTENDED USE TYPE OF WELL 0 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tools D'ia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> i.. Domestic/public Driven F Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor y� <br /> Type of-Pump ` _ H.P. <br /> PUMP REPLACEMENT: . / / State Work Done '. \� II <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter E{ Approximate Depth <br /> Describe Material and Procedure <br /> E� �! <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 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�jthem 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 f TITLE ��� <br /> D W P PLAN.-ON REVERSE SIDE �,.. <br /> kD FOR DEPARTMENT USE ONLY <br /> PHASE I !I �J <br /> APPLICATION ACCEPTED BY DATE _V727 <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIOP . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> s <br />_ I 3/76 , <br /># E 1426 ___Rev. 1- 74 <br />