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SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-�7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,7 <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION "�� /�&m aw CENSUS ,TRACT <br /> Owner's Name JJ te Phone � �� _ <br /> Address ,t,�.0 city /0 <br /> Contractor's Name , License 4� �� Phone <br /> pr <br /> f <br /> I <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/—/ RECONDITION_/ 7 DESTRUCTION /_7 <br /> PUMP INSTALLATION —PUMP REPAIR / / PUMP REPLACEMENT /i7-- <br /> Other <br /> I DISTANCE" TO NEAREST: SEPTIC TANK SEWER LINES -!rdr: PIT PRIVY <br /> ' <br /> - '-SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN 6'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF, WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' ' ,Cable Tool Dia. of Well Excavation Q <br /> Y,rDomestic/private Drilled Dia. of Well Casing rS1 <br /> �Domesiic/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: 'I ; Contractor - <br /> ypez.of Pump nV. o6 jzt. H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: L- :./ /. State Work Done <br /> AES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> f * Describe Material and Procedure <br /> EI 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 notify them before putting the well in use.. The above <br /> linformat on is true to the best of myknowledge and belief. I WILL CALL FOR A .GROUT INSPECTION <br /> EPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> iSIGNED TITLE E <br /> (DRAW PLOT PLAN ON REVERSE SIDE i <br /> J <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f - <br /> i PHASE I OUT N ECTION PHAS SII/FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY 7'(JDATE <br /> 117.7 2M <br /> E H 1426 Rev. 1-74 <br />