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ry SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE-USE: 1601 E. Hazelton. Ave. , Stockton, Calif. C �U L � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 1�Z' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �U r77 <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 R///ules- and Regulations of the San Joaquin Local Health District. A <br /> JOB .ADDRESS/LOCATION Dga,�, CENSUS TRACT <br /> Owner's Name'µf <br /> Phone <br /> Address 71 City <br /> Contractor's Name LicenseIC <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / `PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC=WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ;* CONSTRUCTION SPECIFICATIONS <br /> Industrial K Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br />. ,< Irrigation Grave'I'Pacit ;,: -�. ,;.Depth of Grout Seal -� <br /> Cathodic-Protection Rotary Type of Grout _ <br /> Disposal Other Other Information rz <br /> Geo h sisal Surface Seal Installed <br /> By: <br /> PUMP INSTALLATION: Contractor <br /> Type ofPuMP H.P. <br /> PUMP REPLACEMENT: / / ;S;tate Work Done <br /> PUMP REPAIR: / / State. Work Done r , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ,z0� <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 k <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 noItify 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 G1R0 T INSPECTION <br /> PRIOR TO G TING D A FIN INSPECTION. ,, <br /> SIGNED : TITLE <br /> (DRAW PrOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 _ <br /> APPLICATION ACCEPTED BY or. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY ,,/" DATE z -17 -7 7 INSPECTION BY DATE 2 /7 . 7;? <br /> 2M <br /> G <br /> E H 1426 Rev_ . i-7� N <br />