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SAN JOAQUIN LOCAL HEALTH DISTRICT �O „ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> a � <br /> Telephone : (209), 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 0 <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fox 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. 862 and the Ru s d Reg lations of the San Joaquin Local Health Diatrict. ' <br /> � <br /> I dor ►c o <br /> JOB ADDRESS/LOCATION Q 5 3 Z / CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name y""!t? �,. License' #��hone'� <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/ / RECONDITION / / DESTRUCTION /1. <br /> PUMP INSTWLrATION.,/.-/ PUMI' REPAIR!/ /�7-PUMP REPLACEMENT /7 <br /> -Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES___ SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ,,PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I' CONSTRUCTION SPECIFI ATIONS� �. <br /> Industrial Cable Tool Dia. of. Well Excavation <br /> Domestic/private Drilled Dia.o`f Well- Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation --Gravel Pack Depth-of­Grout. Seal q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By-:-- <br /> PUMP <br /> � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> _ A <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State-Work Ione <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1 ' <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, ] 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 TO GRC91TING A FINAL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE qT -] <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / / 7 7 INSPECTION BY DATE <br /> F: H 142F� Raze- . 7_7L - <br /> ��77 . 2M I <br />