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Y <br /> SAN.JOAQUIN`x LOCAL :HEALTH DISTRICT <br /> f60- OFFICE USE: 1601. E. lHazt1ton-.-Ave'. , 'Stockton, Calif. 7- f, <br /> Telephone:''.'::'.:(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N 7 7' 3J5- <br /> THIS PERMIT:t EXP.IRES..1 .YEARr-FROM DATE ISSUED Date Issued -s-77 <br /> (Complete' In Triplicate) <br /> Application is hereby made to the Sau 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 Joaqui: <br /> County Ordinance No. 186.2 and. the. Rules=and;:.Rcgulations.of,the San Joaquin Local Health District. <br /> LIA <br /> JOB ADDRESS/LOCATION .; CENSUS TRACT <br /> CzOwner's Name Phony _ Eg <br /> Address a. - -° City <br /> Contractor's Name . Lic se. # �` Phon , <br /> TYPE OF WORK (check): NEW WELL17 DEEPEN -/7- RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR /-7—PUMP REPLACEMENT ff . <br /> Other {% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> a SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> fi PROPERTY LINE -- -PRIVATE- DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - boOO Cable Tool Dia. of Well Excavation - G <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 710 <br /> Disposal Other Other Information <br /> .,Ge ophysical Surface Seal Installed By: \, <br /> PUMP INSTALLATION: Contractor �1 <br /> Type of Pump , ., H.P. I TA_- <br /> PUMP REPLACEMENT: / { State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> gELTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure z <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 knowledge and- belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T04ROMENC AND A FINAL INSPECTION. <br /> SIGNED TITLE Q <br /> (DRAW PLOT FLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE <br /> k ADDITIONAL CO101ENTS: <br /> I( PHA E . - GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE .y 22-2 2 INSPECTION BY DATE Lf 7 <br /> H 1426 Rev. 1-74 <br /> - 1-74 2M <br />