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/ N JOAQT'[N LOCAL HEALTH DISTRIC <br /> FOk OFFICE USE: 16(31"E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77/A 3/ u,) <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / M , (p o 'f j3 y — % t r1c f K oS i I `16 <br /> SUS TRACT <br /> Owner's Name h C,- /1 / rt' l Phone <br /> Address bGC) City / rc W C c� <br /> Contractor's Name HQ n' Ai Leu G S f3 kC License lit`!Os/3 Phone i 22— /G-Si <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other /_7 — <br /> DISTANCE 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 C <br /> Industrial Cable Tool Dia, of Well Excavation z <br /> Domestic/private Drilled Dia. of Well Casing 7f, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection T Rotary Type of ,Grout <br /> Disposal Other Other Information S'.( ri , <br /> Geophysical Surface Seal Installed Bv: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �a <br /> PUMP '.REPAIR: /7 State Work Done <br /> r <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 REPO T of the well and notify them before putting the well in use. The above <br /> information is tr a )to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G YD A FINAL INSPECTION. <br /> SIGNED TITLE Ck -tiu J 1' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE lO 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE I SPECTION BY DATE <br /> E H 1426 Rev. 1-74 , <br />