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Co kvv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: C� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-1}Ss <br /> j THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued N n�x.27 <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 Sari Joaquin <br /> County Ordinance No.,W6 an he Rules and 'Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 .irt4 Md, Toste I ./ A _ 'EMSUS TRACT <br /> Owner's Name J4 Phone <br /> ' Cit <br /> Address X'I- � ' y <br /> F Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ '/ RECONDITION / / DESTRUCTION <br /> }' PUMP INSTALLATION / / .., PUMP REPAIR PUMP REPLACEMENT <br /> Other <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 <br /> Industrial Cable Tool Dia. of Well Excavation <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 <br /> r Disposal Other Other Information <br /> Geophysical t Surface Seal Installed By* <br /> PUMP INSTALLATION: Contractorff H.P. � <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t <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 k 1`e`ag' and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T ROUTING AND ANS CT <br /> SIGNED TITLE <br /> RA OT PLAN 0 VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -22 =7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY / DATE ­ <br /> 7 Z <br /> ' 1177 _ 2M <br /> E H 1426 Rev. 1-74 <br />