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i! SAN JOAQUIN LOCAL HEALTH DISTRICTi�' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. k <br /> Telephone :. (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77`130 <br /> THIS PERMIT EXPIRES l YEAR FROM @ATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> t'ol <br /> Application is here .y.-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 /> I <br /> JOB ADDRESS/LOCATION r; 03!12 Rd CENSUS TRACT ' <br /> Owner's Name Z71A Phone <br /> Address city- <br /> Contractor s <br /> ityContractor's Nam License / hon ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> AL _ <br /> PUMP INSTLATION PUMP REPAIR / / ._PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC T ANK'°"S',- SEWER LINES SPIT PRIVY <br /> ,. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. <br /> 'P 4. <br /> LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .� <br /> Industrial V Cable Tool Dia. of Well Excavation <br />�Domestic/private.; brilled Dia. of Well Casing <br /> DOmestic/public Driven Gauge of Casing <br /> Irrigation t s � ;� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection' , Rotary Type of Grout <br /> Disposal 'Other Other Information <br /> Geophysical ' i Surface Seal Installed By: <br /> iI <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / `I/ State Work Done <br /> PUMP .REPAIR:. .., ' M <br /> / / State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED iM TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPARTMENT USE ONLY/ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /��`�' 7 J <br /> ADDITIONAL COMMENTS: 1�. <br /> PHASE GROU INSPECTION PHASE I;,�JFINAIOINSPECTION <br /> INSPECTION B ,E DATE (�-- -7 INSPECTION RX.. DATE,,,,,-_/- _77 <br /> �M <br /> E H 1426 Rev. , 1-7.4 ,i_- <br />