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t .� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I A- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) �✓ ® f <br /> Application is- hereby made to the San Joaquin Local Health District'for a permit to co s77-/Z-7/ <br /> truc <br /> and/or install the work herein described. This application is made iii,,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. je�bll X/ (t-b /y 9 n- f Eta- CENSUS TRACT <br /> Owner's Name S ' <br /> Phone 7 :� <br /> Address <br /> City <br /> Contractor's Name ���R�� (,�y/`+ C� License # 3Z1r/ Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / J RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION MP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br />' DIS'TANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q f <br /> Industrial Cable Tool Dia. of Well Excavation 5 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven 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 C z5 7Y?n Z <br /> Type of Pumper VSA _ . H.P. Z. '�� <br /> PUMP REPLACEMENT: / / State Work Done 6-t S 77-V 7-TJ <br /> PUMP '.REPAIR: / / State Work Donees <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 /> 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 notifjr them before putting the wellin 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 /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ` ._ DATE <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE - I /FIN -INSPECTIOIJit <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1/77. <br />