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. T -_- <br /> 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f1�p-77 <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 /> Zo6o's . ' KaFF -fir' " P1 7 - �zo� 10 <br /> JOB ADDRESS/LOCATION U1 I j fJENSUS TRACT <br /> Owner's Name :.l`J Phone <br /> i <br /> Address / 36 City <br /> 17 <br /> Contractor's Name nn <br /> �1 License Phone34- ,�� <br /> i; <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION / -/ DESTRUCTION /7 <br /> PUMP INSTALLATION/ -PUMP PUMP REPAIR )Fe PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ul <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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1,,f— l <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ f <br /> PUMP .REPAIR: f State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure F. <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 REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A INSPECT N. <br /> SIGNED TITLE ;51-4*/L.1 <br /> RAW PTS T PLAN''ON REVERSE SIDE) 7, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY &A/ DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION 'PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 E 3/76 2M <br />