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L- F <br /> P SAN JOAQUIN LOCALHEALTH.DISTRICTI`USE: 1601 E. Hazelton Ave. , Stockton, <br /> Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 gyp/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6, 2r_,ZZ <br /> (7 (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 $ CENSUS TRACT <br /> Owner's Name' � Phone <br /> Address o City <br /> Contractor's Name License Phone cS <br /> �-TYPE`OF-WORK (Che6k)-C" NEW-WELL " _ PE / RECONDITION F7 DESTRUCTION /_7 <br /> PUMP IN / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> rx <br /> DISTANCE TO NEAREST. SEPTIC TANKQd SEWER LINES pp ' PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL 2_0 ' PUBLIC DOMESTIC WELL <br /> R INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial Cable Tool.-.- 1 _Dia.-,of :Well Excavation " <br /> Domestic/private Drilled Dia. of .Well Casing <br /> Domestic/public Driven Gauge of, Casing o <br /> r.= Irrigation Gravel. Pack, � .Depth,of Grout Seal <br /> Cathodic Protection R Rotary _Type_o_f Grout Cgrm 0_,V <br /> # as ,Disposal ' Other Other Information <br /> 'Geophysical Surface Seal Installed By: <br /> t <br /> 1PUMP INSTALLATION: Contractor <br /> Type-of PumpH.P. <br /> PUP3P.•REPLACEMENT Y'1--. ^ .�/ / �State Work. Done <br /> PUN,E- .REPAIR: / _/ 3 State Work Done <br /> ' DES-TRUCTION�OF-WELL: --Well ame er�, � ; Approximate Depth ' t� <br /> Describe Material and Procedure { <br /> F <br /> II hereby agree- to comply with all laws-arid-regulatior►s -6f--•the-rS-an-Joaquin Local Health District <br /> ? and'the State of California pertaining to or regulatingwell'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 /> . WEL�L, DRILLERS REPORT of the well and notify them before4putting the .well in use. The above <br /> information is true to the best oknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> (PRIOR TO G TING40 A F I ION Fr <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: } <br /> II G OUT INSPECTION PHAS III/FI AL INSPECT ON <br /> ` INSTECTION By � DATE -+ INSPECTION BY DATE 4111 <br /> 'k. - - y0 - 5'� ' 2K <br /> E H 1426 Rev. 1-74 , <br />