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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_ <br /> sC�� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued L_jr�77 <br /> (Complete In. Triplicate) r <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. 1.862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS 6N ZD6-", / x'18 c /j _ CENSUS TRACT <br /> i Owner's Name -t S r Phone , <br /> Address �� City . . <br /> Contractor's Name .., License Phone 91-32M <br /> TYPE OF.WORK (Check): NEW WELL DEEPEN; RECONDITION lT DESTRUCTION f-T <br /> PUMP INSTALLATION "/ PUMP REPAIR / 7 PUMP REPLACEMENT f7 <br /> Other <br /> kDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY `- <br /> SEWAGE DISPOSAL FIELA.ZW CESSPOOL/SEEPAGE PIT` OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL �P� UBLIC DOMESTIC WELT. <br /> INTENDED USE TYPE OF WELL 4,1e CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Y! <br /> Domestic/private .. Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> J 2— <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary F - Type of Grout ` <br /> Disposal Other Other Information . . -_. <br /> Geophysical - Sutrface Seal. Installed"By i Coi,, �.-� .••� <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump H.P. !" . <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> ® Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations 6f 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 /> f <br /> information is,true-to-the-b`e-st--of:' my;knowledge—_ and belief: I WILL LxFOR A GROUT INSPECTION <br /> i PRIOR TO GROUTING AND A FINAL INSPEGTIO ` <br /> SIGNED <br /> y _ PLOT P 0 REVERSE SIDE <br /> PHASE I <br /> FOR DEP TMENT USE ONLY 1 ' <br /> - 14� <br /> APPLICATION ACCEPTED BV , DATE <br /> ADDITIONAL COMMENTS: <br /> 2 PHASE II GROUTFINSPECTION PHA FINAL INSPECTION. <br /> t INSPECTION BY "DATE ;-12 :? INSPECTION BY DATE o-. . .=I j <br /> �. LN <br /> } . T <br /> 2M <br /> E H 1426 Rev. 1-74 <br />