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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> 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-,46,�IJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S- <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. 1862 and the Rules and Regulations of the-San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION TACT -- <br /> Owner's Name Z�_Ar Phone <br /> Address 1A,-19 C2 fi'/ 1)ego `� � d City <br /> 4 <br /> 1 <br /> Contractor's Name iQ� ' �` ` License Xcj Phone34rC�� <br /> TYPE OF WORK (Check) : NEW WELL/Z7--�E_EPEN / / RECONDITION /_/ DESTRUCTION /- <br /> PUMP .INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Otherl/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK4SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE.PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 'PUBLIC DOMESTIC WELL (,v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial', able Tool y, Dias. of Well Excavation V <br /> Domestic/private :';� 1 Drilled _ l` Dian of' Well Casing <br /> Domestic/public Driven a. Gauge _of 1Casing = _/_0 __- <br /> iJ rrigation i Gravel Pack Depth of'Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout _ <br /> Disposal Other _ Other Information '" <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Cont ctor <br /> Type tof Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done / s <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r <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 <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 GR TING AND A FINAL INSPEON. > . <br /> SIGNED TITLE <br /> (DEN PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT-ION.-t PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE i' ! '_ INSPECTION BY-, DATE !S-2 � <br /> a <br /> 46" <br /> E H 1426 Rev. 1-74 3/76 <br />