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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> x FOSx OFFICE USE: 1601 E. Hazelton Ave. ,KStockton, Calif. <br /> Telephone: ' -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No." 77/fezo i <br /> THIS, PERMIT EXPIRES 1 YEAR FROM DATE­ISSUEDi , Date .Issued An�ff,0'11 , <br /> (Complete In Triplicate) <br /> Application is hereby mads to the San Joaquin Local -Health District for i permit ta, co►struct x' <br /> : and/or install the work herein described. This application .is :made •Aw.jcomoliance, with Sen•Joaquin <br /> 'County Ordinance No. 1862 and the Rules and Regulations,,,of the .,San Joaquin L,oc l Health District. <br /> `JOB' ADDRESS/LOCATION .LG/ • , /` ry ( CENSUS TRACT <br /> `Owner's Name• , -> Phone ,.41 4� <br /> ze <br /> }Address, - City . . <br /> ' <br /> Contractor's' Name License #dR Phone <br /> ; <br /> a <br /> XYPE OF WORK (Check): NEW WELL DEEP 7 RECONDITION- f7 DESTRUCTION / T- - <br /> ' PUMP-INST . LATIO PUMP REPAIR'/�- PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK40" <br /> . SEWER LINES , E : PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTAER. s <br /> i PROPERTY LINE '- PRIVATE DOMESTIC WELL '. . PUBLIC DOMESTIC WELL. <br /> -- INTENDED USE TYPE OF WELL CONSTRUCTION,SPECiFICATIONS <br />' + Industrial. Cable Tool Di'a..of !Well °Excavation \ <br /> Domestic/private Drilled Dia. of Well"tasin <br /> Domestic/public Driven Gauge of Casing- • <br /> Irrigation - Gravel Pack Depth of Grout Seai <br /> Cathodic Protection' Rotary Type of Grout <br /> - Disposal Other Other� Information !' <br /> Ik Geophysical Surface 'Seal' InstAlledB s <br /> y <br /> PUMP INSTALLATION: ` Contractor <br /> Type of Pump H.P. , <br />` PUMP REPLACEMENT: Lj State Work Done <br /> r{ <br /> PUMP ,REPAIR: <br /> State Work Done f <br /> ,DES-TRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Material and Procedure <br /> iI hereby agree, to comply with all laws- and regulations of the San, Joaquin Locsl. Health District <br /> And, the State of California pertaining, to or regulating well`construction:,'. Within FIFTEEN DAYS <br /> 1after completion of my work "on anew well, I,will furnish the San Joaquin Local. Health District W <br /> DELL ,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 Witt"CALL -FOR A GROUT: INSPECTION l <br /> P-k IOR TO GROUTING -AND A FINAL, INSPECTION. ; <br /> SIGNED - TITLE` Lcl�� <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> i" FOR'DEPARTMENT USE ONLY r <br /> PHASE I <br /> APPLICATION ACCEPTED BY zDATE. �Z <br /> 'ADDITIONAL COMMENTS <br /> t <br /> "^ PHASE II GROUT INSPECTION PHASFA III Im INSPECTION <br /> WSPECTION BY DATE: INSPECTION BY ATE <br /> t ' E H 1426 Rev. 1-74. . !x/75 2M <br />