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v e4N JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 16 _ E. Hazelton Ave. , Stockton, Car). <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <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 Rul nd RegulationA of the San Joaquin Loc h,District. <br /> 1 <br /> JOB ADDRESS/LOCATION ri �`-��ESUS <br /> Owner's Name 2Jj-9 '0 Jw G <br /> Phone <br /> t <br /> Address - City <br /> Contractor's Name ?-­7� 7-� ,/�A <br /> License Phones` <br /> TYPE OF WORK (Check): MEW' WELL '/-7 DEEPEN -/_7 RECONDITION /_ -DESTRUCTION _ <br /> PUMP INSTALLATION PUMP REPAIR '/—/ PUMP REPLACEME T L7 <br /> Other. <br /> 1/7 <br /> DISTANCE TO NEAREST: SEPTxC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE PISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMEST C WELLS <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well. Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic1public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal 1 Other Other Information ' <br /> Geophysical <br /> Surface Seal Installed B ,: - <br /> C <br /> PUMP INSTALLATION: Contractor : , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> -PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well lameter Approximate Depth <br /> PP P <br /> Describe Material and Procedure <br /> I 'hereby agree to comply withlall laws and regulations of the San Joaquin Local Health Distriet, 4 <br /> and the State.:of California pertaining to or regulating well•construction. Within FIMXN *g <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health. Distr 4t <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The abi6ve <br /> information is :true to the-best of- my knowledge and belief. I WILL CALL FORA GROUT IOSPZCTION <br /> PRIOR TO PRO TING AND,.A FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> D W PLAN ON RMkSE SIDE {. . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED EY DATE -� <br /> ADDITIONAL. OOM'MUTS: <br /> PHASE II G jNsPBCTION PHAS F INSPECTION <br /> INSPECTION B _'.� INSPECTION B DATE - <br /> E H 1426 Rev. 1 74 76 <br />