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_� !t� SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> e,,'OF. OFFICE USE: 1601 ,E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77v F <br /> ildeTHIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 3��� -7? <br /> (Complete In Triplicate)Application is hereby to the San Joaquin Local Health District for a permit to construct <br /> and/or .install the world herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 .aand the Rules and' Re ulation�jc' of the San Joaquin Local Health District': <br /> JOB ADDRESS/LOCATION % 4_+ / r CENSUS TRACT <br /> Owner's Named Phone <br /> Address. �L2O CityT� <br /> Contractor's NameLicense �d�hone 9Xg <br /> TYPE OF WORK (Check) . .,NEW WELL DEEPEN/ / RECONDITION /� DESTRUCTION /_7 <br /> ITUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK o, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS IELD �1 _ ; � CESSPOOL/SEEPAGE PIT OTHER <br /> ► PROPERTY LIN �IVATE�DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `.:, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ZC2 <br /> Domestic/public Driven Gauge of Casing /Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �><' Rotary Type of Grout y � <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP -INSTALLATIOI ':!Contractor <br /> Type of Pump l T H.P. /cam' <br /> i PUMP REPLACEMENT: I/ / State Work Done <br /> PUMP .REPAIR: i / / State Work;Done <br /> DESTRUCTION OF WEL-Lf. j�Well Diameter , ,.( �f Approximate Depth /6o <br /> z " Describe Material and'Procedure / <br /> 11 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 n a well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o w 11 and notify them before putting the.-well in- use. The above <br /> ' information is •true ;the best of my :knowledge and belief:, I WILL CALL FOR A GROUT INSPECTION <br /> 'PRIOR TOGROUT G A 0 ...� <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ONYREVERSE SID <br /> II FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> , APPLICATION ACCEPTED BY DATE -2,\ <br /> ADDITIONAL COMMENTS: - <br /> PHASE— -CR-0 INSPECTI PHASE- III FINAL INSPECTIO <br /> , INSPECTION BY ; DATE , `�A INSPF,CTYON BY E►. DATE <br /> E ,H- 1426 Rev. 1-7.4 <br />