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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS QEFICE USE:-- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> 77-?_'-3 1'0 <br /> THIS1PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued 7_/'j4-�7 <br /> (Complete in Triplicate) ' <br /> Application is hereby de tonthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereini described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and#the Rule a Regula ions of the San Joaquin Local Health District. <br /> < �/ ,� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name a -c\OC1 _ Phone ZZ-- 1Ci`k1 <br /> Address <br /> j ! �'O.License # 2�n Phone ' <br /> Contractor s Name � <br /> yj <br /> TYPE OF WORK (Check) NEW WELL f 1: DEEPEN / / RECONDITION ./_:/ -.,DESTRUCTION /� Q <br /> PUMP INSTALLATION Irl —PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> ,Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SQ'-SPIT PRIVY TNO <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ` - BOTHER <br /> PROPERTY L=--PkIVATF DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool I Dia. of Well Excavation 41 <br /> Domestic/private Drilled f Dia. of Well Casing 5lsllll ; <br /> Domestic/public ytl Driven '. Gauge of Casing �'12 Qa �- <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 B <br /> FJMP�tINSTALLATION: Contractor _ <br /> .-4 -_--- -T- a of Pum -H.P. <br /> �YP ;p� <br /> PUMP REPLACEMENT: /T/ mmState 'Work Done <br /> PUMPREPAIR:- ��. � /_/ �S ate'inlork Done;, ' <br /> DESTRUCTION"OF-WELL:"'-'Well°-Diameter <br /> - Approximate-Depth - x <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 my work on a new well, I will furnish the San Joaquin Local 'Health District a <br /> WE DRILLERS REPORT of the well d notify them before putting the .well in use. The above <br /> inf ion is true to the bes o m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A FI N CT 0" <br /> SIGNED TITLE <br /> I <br /> �.�R�kPLtOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY 0 <br /> SE I <br /> DATE <br /> APPL PTED BY --�- <br /> f ADDITIONAL COMMENTS: <br /> 6 PHASE II GROUT INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE IJP INSPECTION BY DATE _.-. <br /> AV 'l i - d 3/76 2M y <br /> t E H 1426 Rev. 1-74 <br />