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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �- ]� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Z77-6 12ee) <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 Rules a�nd.Re gulations of the San Joaquin..Local Health District. ! <br /> JOB ADDRESS/LOCATION N&E of '��-"r� I Mor�e��or� �, ... -_ CENSUS TRACT <br /> Owner's Name 'J Gc� �F, �� fig. Phone 9-57-e 33 1 <br /> i <br /> Address 3.1 f`F 10 L,4cvc <br /> ,1 <br /> Contractor's Name 1�.�✓ Linse # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION ` ` <br /> ! PUMP INSTALLATION'f / PUMP REPAIR/ / PUMP REPLACEMENT-'f' /� <br /> 6therf' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LIKE S 1.0 PIT PRIVY 4 <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 <br /> Industrial )K °.-..Cable Tool Dia. of Well Excavation :r <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 x <br /> Disposal Other Other Information / <br /> Geophysical 1, Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of,Pum�"m'�`='";' H.P. <br /> Ci <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: ;� / / State Work Done <br /> Q <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth W,70 <br /> ® — De cr'be Material and Procedure <br /> r <br /> I hereby agree to comply with a l Laws and regulations of th# San Joaquin cal Health D t-1 <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 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 TOG G AND A. F AL INS CTION. <br /> SIGNEDTITLE Qc✓ �w -- - <br /> d�3 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE-ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A DATE g'-�17 <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PWEIJAIIYANAL INSPECTION <br /> INSPECTION BY DATE INSPECTTON BY �i+-� DATE 7 <br /> E -H 1426 Rev. 1-74 :. _ <br />