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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O FI.GEtiUSE: ;1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77-Mol <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued0- <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 96h�� a �� CENSUS TRACT <br /> - a <br /> Owner's Name ,]^ � G, Phone 44 - <br /> i <br /> Address ( Ll 7. le,L u/ city <br /> Contractor's Name 4o,.. //,,,, Cop License Phone E9Z'V7a0 <br /> _ s <br /> TYPE OF WORK (Check) : NEW WELL ,L3j� DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 's <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK`7 C . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE = PRIVATE DOMESTIC WELL.;;�D PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF 'WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation k <br /> Domestic/private <br /> Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing /6 a .k►f i pfr� <br /> Irrigation - Gravel Pack Depth of Grout Seal s-p <br /> Cathodic Protection },w- Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r E <br /> Type of Pump S'Ug h1L-Q.1t/ft434.Ci. - _,_.._._-.._.. H.P. <br /> PUMA' REPLACEMENT <br /> / / State Work Done i <br /> PUMP REPAIR: /, / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proc dure <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 I <br /> WELL DRILLERS REPORT of the well and notify them before putting- thewell 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 TO GROUTING AND A FINAL I PECTION. <br /> SIGNED gag TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHAGE I <br /> 'FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P W E GROUT INSPECTION_ PHAS I/FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE <br /> f <br /> E H 1426 Rev. . 1-74 n,�7.7 &Qn 4 <br />