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.•= _^___ Al SAN JOAQUIN LOCAL- HEALTH DISTRICT <br />{ FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �- Telephone:. (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 SSti[�J <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> In Triplicate) <br /> Application is hereby made to the San (CompleteJ 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/LOCATIQN © �, CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address ' <br /> City <br /> Contractor's Name -� <br /> License #2 !/Y Phone <br /> TYPE QF�WORKr(Check) : NEW WELL DEEPEN // RECONDITION /-7 DESTRUCTION /- <br /> . PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/2U SEWER LINES PIT PRIVY <br /> } SEWAGE DTSP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL W- ° PUBLIC DOMESTIC WELL <br /> INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial � A Cable Tool Dia. of Well Excavation 'j fl k <br /> _ Domestic/private Drilled %Dia, of Well Casing > <br /> Domestic/public Driven Gauge-.,ofCasing <br /> Irrigation 1 Gravel Pack Depth of �Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' ! Other Other <br /> - ' <br /> Other Information <br /> Geophysical `,Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. `# <br /> State Work Done' <br /> PUMP REPAIR- _�„ <br /> / /, -State Work Done;,— <br /> DESTRUCTION OF 'WELI:: `i"Well Diameter - <br /> ppraximate Depth <br /> .Describe Material and Procedure <br /> I hereby agree .to cbmply• with all :1`aws�,and_, r--egulWtions of the• San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well•'e.onstruction. Within FIFTEEN DAYS <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 notify them before putting the..well in use. The above <br /> information is `true to the best' 'of my nowledge and belief! I WILL CALL FOR A GROUT INSPECTION, <br />'RIOR TO G ING AFI .L 'Sp , � <br /> :fit <br /> SIGNED - --��-•---T c At <br /> _ <br /> (DRAW PLOT PLAN`"'ON REVERSE SIDE) <br />?RASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � <br /> 'PLICATION ACCEPTED BY f <br /> DATE <br /> LDDITIONAL COMMENTS: <br /> P E I GR T INSPECTION, 4 s PHASE Ili/FINAL INSPECTION ' <br />:NSPEC bO�. BY DATE INSPF,CTION BY DATE <br /> {' <br /> 1 <br /> 1426 Rev. 1-74 �G'4deep 1X77: ant <br />